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

Cardiology - Exercise Physiology

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


CARDIOLOGY– EXERCISE PHYSIOLOGY CLINICAL TRAINING CHECKLIST ----- This is 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
Data collection prior to tests:
Patient’s personal and family health history, including risk factors for heart disease.
Patient’s perception of current problem
Onset of precipitating factors, to worsening symptoms or alleviating factors and timing
Accompanying factors to patient’s conditions – such as
SOB with CP and arm radiation with CP

Recent vital signs *
Current medications
Purpose for test
Determinations prior to tests:
Appropriateness of test (ETT versus nuclear, walking or chemical), possible

Patient’s risk for test (low, moderate, high)
Pre-test medication instructions
Need for discussion of medication protocol with supervising or ordering physician
Phone calls prior to tests:
Verbal instructions given to patient (attire, length of time, location, medications,
caffeine, diet)

Appropriate message left on machine when necessary (HIPPA guidelines)
Answer questions pertaining to test
Patient pre-test interview (in clinic):
Elicit patient’s expectations in medical care
Determine patient’s knowledge level/deficit and ability to understand
Identify cultural practices related to care
Elicit info regarding relationships with significant others

AREA OF ORIENTATION Discussed Observed Preceptor’s Signature Completed date
Determine smoking history, current medications, and allergies and document

Demonstrate competency in 12-lead ECG *
Listen to heart and lung sounds
Speak with supervising cardiologist when appropriate – examples include:
change in ECG, high BP, LBBB, significant ST segment changes (elevation,
depression), any other questionable feature that raises concern

Select appropriate test protocol
Diagnostic Tests (ETT, nuclear, 12-lead ECG, Holter/event monitor)/Procedures
Demonstrate working knowledge of Case 2000 Exercise Testing System
Administer sub maximal and maximal exercise tests on low, moderate, and high risk
populations and determine appropriate endpoints for stopping tests

Document patient symptoms and take appropriate action when necessary
Recognize ECG changes, document, and take appropriate action when necessary
Record, analyze, and interpret results of tests
Demonstrate ability to document patient progress notes for clinicians and physicians
Demonstrate ability to provide discharge and follow-up plan for patient
Provide technical support for resting 12-lead ECGs, Holter, and event monitors
Educate patients on Holter monitors
Hook Holter monitor up to patient according to protocol
Instruct patient in keeping diary of activities and symptoms
Urgent/Emergency Care
Initiate ECG monitoring (if indicated) * & Initiate Defibrillation (if indicated)
Appropriately care for patient requiring an ECG interpretation
Appropriately care for patient requiring anti-arrhythmic medication
Initiate Chest Pain Protocol appropriately (see Emergency Procedures Manual)
Appropriately care for patient requiring anti-anginal medication
Appropriately care for patient with cardiopulmonary arrest (until advanced help arrives)
Understand and can appropriately set-up the crash cart
Patient Education
Provide follow-up exercise prescriptions when necessary
Demonstrate competence in counseling (cholesterol, hypertension, smoking,


AREA OF ORIENTATION Discussed Observed Preceptor’s Signature Completed date
Assure all equipment/supplies are available based on patient needs – IV supplies
Assure all equipment functions before use – IMED, EKB, TM, Pulse Ox Doppler
Assure all emergency equipment/supplies are current and available at all times
Demonstrate competence in the care of 1st line drugs, defibrillator

Proper and complete labeling of specimens and paperwork (in needed)


I, _________________________________________ (employee name) have completed the EXERCISE PHYSIOLOGY CLINICAL TRAINING
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/Exercise Physiologist(circle one).

__________________________________________________ ___________________
Preceptor Date

____________________________________________________ ___________________
Supervisor Date

__________________________________________________ ___________________
Provider Date

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

Initially Completed 2/07; updated 2/11, 9/11, 3/12, 2/13, 6/14, 3/17

 Send the original signed Clinical Training Checklist to Clinical Staff Education - 1035.
 One copy of the signed Clinical Training 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. (2002). Clinical nursing skills & techniques. (5th 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.