Learning and Development,

Departments & Programs,UW Health,Ambulatory Education,Ambulatory Orientation,Checklists - Core and Department Specific,Resources


Vascular - Departments & Programs, UW Health, Ambulatory Education, Ambulatory Orientation, Checklists - Core and Department Specific, Resources


VASCULAR SURGERY CLINICAL TRAINING CHECKLIST ----- Due three months from hire date------

Employee Name: __________________________________ Employee Credentials:________ Hire Date: ____________

Clinic Location/ number: _______________________ Employee Number ________________________

N/A on checklist indicates that it is not indicated for the employee
*Refer to appropriate UWMF policy Each area should either be discussed or observed by preceptor
AREA OF ORIENTATION Discussed Observed Preceptor’s Signature Completed date
Employees attends Ambulatory Orientation
Employee (RN) is able to demonstrate competence regarding:
Assess patient with acute vs. chronic vascular disease
When to schedule a patient for a clinic appointment
When to send a patient to the Emergency Department
Completing Pre-visit management
Coordinating vascular lab and provider appointments

Employee is able to gather data relevant regarding the following:
Patient’s personal and family health history
Patient’s perception of current problem
Onset of precipitating factors, to worsening symptoms or alleviating factors and timing
Accompanying factors to patient’s conditions
Patient’s expectations in medical care
Patient’s knowledge level/deficit, ability to understand and how to access interpreter
Patient’s cultural practices related to care
Patient’s relationships with significant others
Comply with HIPAA regulations
Obtains vital signs, clinical/ health history, past medical/surgical history, social/family
history, and pull up scans on PACS

Complete FMLA forms
Completes vital signs including BP, Temperature, Respirations, Height & Weight
Check medications/allergies/pharmacy
Update clinical/health, past medical/surgical, social/family history, including alcohol
and smoking history


Discussed Observed Preceptor’s Signature Completed date
Employee is able to demonstrate competence regarding rooming the

Pre-operative Workups
Prior to appointment, review surgery and pre-operative checklist.
Include appropriate test results for provider at time of appointment

Enter progress note to include procedure, MD, date and location of surgery
Provide patient with the appropriate surgical information folder

Post-operative Follow-ups
Review operative note and discharge summary if available
Review surgeon’s notes
Remove dressings and/or ace wraps
Check quality of wound
Measure wound sizes if an open wound

Follow-up Patients
Pull up last office note/vascular lab studies and who saw patient previously
Provide current vascular lab studies
Ask about new problems

Patients with Wounds
Note the type of dressing that the patient had in place
Note the color and amount of drainage and when the dressing was last changed
Cleanse wounds
Ask about fevers or chills- obtain temperature if patient responds yes
Measure wound once per week
Have adequate dressing supplies on hand

Employee is able to demonstrate competence in stocking rooms:
Stock all clinic rooms daily with appropriate and sufficient supplies
Check supplies once per month for expired items
Order supplies as needed

Employee is able to demonstrate competence placing orders:
For scans, labs, prescriptions, and other testing as needed

AREA OF ORIENTATION Discussed Observed Preceptor’s Signature Completed date
Employee will demonstrate competence in patient/family teaching regarding:
Wound care
Unna boot/ Profore boot/ Badger boot care
Drain care
Varicose vein prevention
Pre-op teaching related to vascular testing, procedures and surgery
Post-op complications

Employee will demonstrate competence in appropriately care for a patient
with the following:

Unna boot
Profore boot
Badger boot
Simple wound care (i.e. abx, normal saline damp to dry, or silvadene and 4x4 with kerlix
or betadine to wounds)

Complex wound care (i.e. wound vac or multiple dressing to multiple wounds)
Suture staples
Proper and complete labeling of specimens and paperwork (as needed)

Employee will demonstrate competence regarding the following surgical-
related items:

Schedule and Pre-authorizations
Surgical agreements and pre-operative packets
Labs, imaging, EKG, other pre-operative testing

Employee will demonstrate ability to consults/referrals to other departments:
i.e.: HVT, Cardiology, Oncology, Smoking Cessation

Employee will demonstrate ability regarding Equipment and Supplies:
Assure all equipment/supplies are available based on patient needs
Assure all equipment functions before use
Assure all emergency equipment/supplies are current and available at all times
Order wound vacs
Order Apligrafs from tissue bank
Order other supplies as needed

AREA OF ORIENTATION Discussed Observed Preceptor’s Signature Completed date
Procedures- Demonstrate competence to assist/patient care/follow-up
set-up and clean up

Compartment measurements
Draining hematomas and seromas
Nerve blocks
Thrombin injections for pseudoaneurysms

Procedures- Demonstrate competence to set-up and clean up
Compartment measurements
Draining hematomas and seromas
Set up sterile field for procedures
Proper and complete labeling of specimens and paperwork (as needed)
Obtain consents for patients

Administration of Medication:
Understands the following drug compatibility’s:
Lidocaine Polidocanol Sotradecyl
Solumedrol Bupivocaine Uses for Silver Nitrate
Properly disposes of expired medications
Properly disposes of unused or discarded or refused medications

Employee will demonstrate ability to complete Previst Planning for New
Patients to the Vascular Clinic


I, _________________________________________ (employee name) have completed the Core Competency Checklist and attest the information
is true and valid. I have demonstrated or discussed these skills and I am responsible for performing patient care as a Certified Medical Assistant /
Licensed Practical Nurse / Registered Nurse (circle one).

__________________________________________________ ___________________
Preceptor Date

____________________________________________________ ___________________
Supervisor Date

__________________________________________________ ___________________
Provider Date

Additional Preceptor Signatures/initials:
1. _________________________________________________
2. _________________________________________________
3. _________________________________________________
4. _________________________________________________

Initially Completely 5/22/2014, 7/2/2015

 Send the original signed Core Competency Checklist to Clinical Staff Education - 414.
 One copy of the signed Core Competency Checklist should be placed in the clinic’s staff employee’s file, and a copy given to the employee.

Brener, T., Doyle, R.M. (Ed.). (2008). Nursing 2008 drug handbook. Philadelphia, PA: Lippincott Williams & Wilkins.
Perry, A.G. & Potter, P.A. (2006). Clinical nursing skills & techniques. (6th ed.). St. Louis, MO: Mosby.
Perry, A.G. & Potter, P.A. (2009). Fundamentals of nursing. (7th ed.). Hall, A. & Stockert, P.A. (Eds.). St. Louis, MO: Mosby Elsevier.
Vascular Surgery Preoperative Protocols
Vascular Surgery Postoperative Protocols