Procedural Competency Form
Procedural Competency Form
Endotracheal Intubation
Resident:_______________________________________ Date:__________________
Observing faculty:________________________________
Checklist of performance:
|Pre-procedure |Yes |No |N/A |
|Obtains informed consent when appropriate | | | |
|Evaluates airway for potential difficulty | | | |
|Pre-oxygenates patient | | | |
|Prepares and checks equipment | | | |
|Positions patient correctly | | | |
|Verbalizes back-up plan to supervising physician | | | |
|Procedure | | | |
|Observes universal precautions | | | |
|Orders appropriate medications | | | |
|Correct timing of medications delivered | | | |
|Utilizes cricoid pressure appropriately | | | |
|Maintains cervical stabilization (if applicable) | | | |
|Initiates intubation attempt at correct time | | | |
|Utilizes the laryngoscope appropriately | | | |
|Handles and passes ET tube appropriately | | | |
|Recognizes need to abort attempt and oxygenate | | | |
|Initiates back up plan appropriately if indicated | | | |
|Post-procedure | | | |
|Verifies tube position | | | |
|Secures tube | | | |
|Orders and reviews post intubation chest x-ray | | | |
|Orders appropriate ventilator settings | | | |
|Orders appropriate chemical sedation if indicated | | | |
Assessment (circle one): Unsatisfactory Satisfactory
Comments:
Faculty signature:______________________________________________________________
Resident signature:_____________________________________________________________
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