4/8/24, 10:42 PM Endoscopy Checklist
Endoscopy Checklist
NAME
LAST 4 OF SSN
DATE
I hereby certify that ALL information I have provided on
this skills checklist and all other documentation, is true
and accurate. I understand and acknowledge that any
misrepresentation or omission may result in
disqualification from employment and/or immediate
termination.
Instructions: This checklist is meant to serve as a general guideline for our client
facilities as to the level of your skills within your nursing specialty. Please use the scale
below to describe your experience/expertise in each area listed below.
Proficiency Scale: 1 = No Experience
2 = Need Training
3 = Able to perform with
supervision
4 = Able to perform
independently
Rating Stars (Click) Procedures 1 2 3 4
Assist with EGD’s
Assist with endoscopic ultrasound
Assist with active GI bleed
Cautery devices
Assist with manometry studies
Assist with variceal banding
Assist with esophageal dilatations
Assist with esophageal ballooning
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4/8/24, 10:42 PM Endoscopy Checklist
Assist with scelrotherapy
Assist with TEE
Assist with bronchoscopy
Assist with colonoscopy
Assist with polypectomy
Assist with ERCP’s
Assist with PEG placements
Assist with liver BX
Assist with collection of hot & cold BX’s
Specimen collection & labeling
Set up of scopes & video equipment
Apply external abdominal pressure to assist
with scope movement
Scope cleaning
Assist with mobile cases, ICU, ER, etc.
Radiation safety
Automated Medication Dispensing System,
Pyxis, Omnicell, or other
Takes call for emergency cases
National Patient Safety Goals
Awareness of HCAHPS
Accurate patient identification
Effective communication
Interpretation & communication of lab values
Medication administration
Anticoagulation therapy
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4/8/24, 10:42 PM Endoscopy Checklist
Monitoring conscious sedation
Pain assessment & management
Infection control
Universal precautions
Isolation
Minimize risk for falls
Prevention of pressure ulcers
Use of rapid response teams
Administer Conscious Sedation
Fentanyl
Propofol
Demerol
Presedex
Versed
Reversal agents
Pre Procedure
Pre procedure phone calls
Electronic documentation
Patient assessment
Colon prep or re-prep
Pre procedure checklist/consent
IV start, med admin
Post Procedure
Assess for air movement post colonoscopy
Assess for pain
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4/8/24, 10:42 PM Endoscopy Checklist
Assess for bowel sounds
Assess for gag reflex post EGD
Assess for gag reflex post bronchoscopy
Recover from MAC
Recover from (moderate) conscious sedation
Discharge outpatients to home
Post procedure phone calls
Rating Stars (Click) Age Specific Competencies 1 2 3 4
Newborn/neonate (birth-30 days)
Infant (31 days-1 year)
Toddler (ages 2-3 years)
Preschool (ages 4-5 years)
School age (ages 6-12 years)
Adolescent (ages 13-21 years)
Young adult (ages 22-39 years)
Adult (ages 40-64 years)
Older adult (ages 65-79 years)
Elderly (ages 80+ years)
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