Advanced Prescribed Procedure Certification Program Checklist

Facility

Address

Contact Person

Telephone

Email Address

Procedure: Procedure: Manipulation or repositioning of a cannula balloon. Chest needle insertion, aspiration, reposition and removal. Chest tube insertion, aspiration, reposition and removal. Bronchoscopic tissue sample for the purpose of bronchoalveolar lavage and endobronchial brushing. Intraosseous needle insertion. Subcutaneous electrode placement for interoperative and perinatal fetal monitoring.

Patient Population: Patient Population: Adult Pediatric Neonatal

Submission: Submission: Initial Revision to an approved program

Date of previous submission (if applicable):

Authorization: Authorization: The procedure is an advanced procedure below the dermis as defined by O. Reg 596/94, Part VII and the procedure is authorized by the CRTO for performance by Respiratory Therapists. The procedure is being performed by Members of the CRTO who are permitted to perform advanced prescribed procedures (I.e., General certificate of registration). Performance of the procedure by RTs has been approved in a policy by the Member’s facility.

Curriculum: 1. The certification curriculum considers the following: Curriculum: 1. The certification curriculum considers the following: Hours of instruction Methods of instruction Assessment of knowledge and experience

Curriculum: 2. The certification curriculum content includes: Curriculum: 2. The certification curriculum content includes: Performance based objectives Nature and purpose of the procedure Conditions specific to the individual institution/facility under which the procedure is to be performed Associated anatomy, physiology, pathophysiology and pharmacology Indications and contraindications Risk factors and potential complications Management of complications Technique - demonstration, supervised training, skill evaluation

Quality Assurance: Quality Assurance: The initial certification process requires the member to demonstrate that he/she possesses the appropriate clinical competence for all components of the procedure. The certification process has a system for initial instruction, evaluation and re-evaluation (recertification). A re-certification (minimum schedule of every 2 years) process is in place that includes a hands-on demonstration of competence and may include a review of related experience and a verbal/written evaluation of knowledge.

Records: Records: Records: The process identifies the individual(s) within the institution who is (are) responsible for certifying and re-certifying those members performing the procedure. Records of instruction, certification and re-certification are maintained and retained by the institution.

Name

Type name for signature:

Title

Date