Every ACLS provider card ends the same way: an instructor holding a clipboard, watching you run a code. That clipboard is the ACLS skills check off, and the American Heart Association publishes the exact checklists it uses. You're graded on the Adult High-Quality BLS Skills Test and the Megacode Test, and both come with a printed list of critical performance steps. Miss a step marked critical and you get remediation. Nail every one and you walk out certified for two years.
Every ACLS provider card ends the same way: an instructor holding a clipboard, watching you run a code. That clipboard is the ACLS skills check off, and the American Heart Association publishes the exact checklists it uses. You're graded on the Adult High-Quality BLS Skills Test and the Megacode Test, and both come with a printed list of critical performance steps. Miss a step marked critical and you get remediation. Nail every one and you walk out certified for two years.
This guide walks through the real AHA skills testing checklist line by line. You'll see what the BLS station measures, what the airway station expects, and how the Megacode scenarios are scored. We've also included the timing rules that trip people up, like the 18-second compression cycle limit and the two-minute rhythm checks. If you've finished the HeartCode ACLS online portion and your hands-on session is coming up, this is the part you need.
The checklist isn't a secret. Instructors are told to review it with students before testing starts, and plenty of training centers hand out copies. Still, most candidates read it once and forget half of it under pressure. That's exactly why you should practice with it early. Pair this walkthrough with the acls algorithms and you'll know both what to do and what the evaluator is watching for.
The AHA runs ACLS two ways, and both end at the same skills check off. The classroom route is a one- or two-day acls course where lectures, practice, and testing happen together. The blended route is HeartCode ACLS: you finish Part 1 online with simulated patients, then show up for a hands-on session that covers Part 2 (practice) and Part 3 (testing). Either way, the instructor uses the same official checklists to decide whether you pass.
There are three things you'll be evaluated on in person. First is the Adult High-Quality BLS Skills Test, which is compressions, ventilations, and AED use on a manikin with feedback. Second is airway management, where you insert an oropharyngeal and nasopharyngeal airway and ventilate with a bag-mask device. Third is the Megacode Test, a full team-based scenario where you act as team leader through several rhythm changes. Classroom students also sit a 50-question written exam, which HeartCode learners complete online.
People sometimes expect a lecture-style day and get surprised by how much hands-on time there is. The american heart association acls course is built around practice-while-watching video, so you'll rotate through stations before anything is formally scored. Testing comes last. Show up knowing the checklists and the practice stations become a rehearsal instead of a scramble.
The BLS station comes first because everything in ACLS rests on it. The checklist starts with assessment: check responsiveness, shout for help, activate the emergency response system, and check breathing and pulse at the same time for at least five but no more than ten seconds. Then you begin cycle one. The evaluator wants 30 compressions and 2 breaths, with the whole cycle finished in 18 seconds or less. Hands go on the lower half of the sternum, rate 100 to 120 per minute, depth at least 2 inches with full recoil.
Cycle two is where the AED arrives. You keep compressing while a second rescuer powers it on, and you clear the patient for analysis and for the shock. The critical step people forget is resuming compressions immediately after the shock, not waiting for the machine to talk. The checklist also scores whether you minimize interruptions and switch compressors during the rhythm analysis. Feedback manikins now report your rate and depth, so the numbers are objective.
Several steps on this sheet are marked critical, meaning one miss triggers remediation. Those include starting compressions within ten seconds of confirming no pulse, delivering effective breaths that make the chest rise, and resuming CPR right after each shock. Practicing on a real manikin beats reading about it, but you can drill the sequence anywhere. Run through an acls practice test alongside your physical practice so the order becomes automatic.
Most Megacode scenarios open with symptomatic bradycardia. The checklist scores whether you start oxygen if needed, place the monitor with leads in the correct position, and establish IV access. You must verbalize that the patient is symptomatic, meaning hypotension, altered mental status, chest pain, or signs of shock. Then you order the correct first-line drug: atropine 1 mg IV push, repeated every 3 to 5 minutes to a maximum of 3 mg.
The evaluator also expects you to prepare a second-line treatment before the patient deteriorates. That means calling for transcutaneous pacing or an infusion of dopamine or epinephrine. Saying the words counts. What fails candidates here is jumping to pacing without atropine, or forgetting to reassess after each intervention. State the plan out loud so the team and the instructor hear it.
When the rhythm converts to ventricular fibrillation or pulseless VT, the checklist gets strict. You have to recognize the shockable rhythm, clear the patient before analysis and again before the shock, and make sure compressions resume immediately after. The instructor watches for appropriate cycles: CPR for two minutes, rhythm check, shock, resume CPR, then drug. Epinephrine 1 mg IV/IO goes in every 3 to 5 minutes after the second shock.
After the third shock, you order amiodarone 300 mg IV/IO, with a second dose of 150 mg if VF persists. Lidocaine 1 to 1.5 mg/kg is the accepted alternative. You'll also be graded on airway management during the arrest, which means bag-mask ventilation or verbalizing an advanced airway with waveform capnography. Consider reversible causes throughout, and keep the team communicating.
The non-shockable branch tests whether you recognize PEA or asystole and refuse to shock it. The checklist wants continuous high-quality CPR, epinephrine 1 mg as soon as possible and every 3 to 5 minutes, and a spoken review of the reversible causes. That's the Hs and Ts: hypovolemia, hypoxia, hydrogen ion (acidosis), hypo- or hyperkalemia, hypothermia, tension pneumothorax, tamponade, toxins, thrombosis pulmonary, and thrombosis coronary.
The scenario usually ends with return of spontaneous circulation, and post-cardiac arrest care is scored too. You must identify ROSC, order blood pressure and a 12-lead ECG, keep oxygen saturation between 92 and 98 percent, and verbalize the need for an advanced airway with capnography. Naming targeted temperature management for a patient who doesn't follow commands earns the final check mark.
The airway station is short but it catches people who haven't touched the equipment. You'll size an oropharyngeal airway from the corner of the mouth to the angle of the jaw and insert it correctly, then size a nasopharyngeal airway from the nostril to the earlobe and lubricate it before insertion. After that comes bag-mask ventilation using the E-C clamp technique, with each breath delivered over one second and just enough volume to see the chest rise. Squeeze too hard and the manikin's stomach inflates.
Timing matters here as much as in the Megacode. Without an advanced airway, you ventilate at a 30:2 ratio. Once an advanced airway is in place, the rate becomes one breath every six seconds with continuous compressions. Instructors will ask you to confirm placement with waveform capnography and to interpret the reading. A PETCO2 under 10 mmHg means compressions need work; a sudden rise to 35 or 45 usually means ROSC. The acls protocol puts capnography at the center of quality monitoring for exactly this reason.
You won't be required to intubate. ACLS teaches endotracheal intubation and supraglottic airways as concepts, but the skills test only requires you to verbalize the plan and manage the basic airway well. What the sheet does score is suctioning when needed, avoiding excessive ventilation, and coordinating breaths with the compressor. Study the acls bradycardia algorithm too, because the airway station often flows straight into a bradycardia scenario at the same manikin.
You're graded as the team leader, not the person doing compressions. The checklist asks whether you assigned roles, ensured high-quality CPR at all times, and kept communication closed-loop. Directing the team clearly earns points even when a team member makes a small error.
Each Megacode scenario lists specific critical steps such as clearing before shocks, correct drug doses, and resuming CPR immediately. The instructor checks each one as performed or not. Every critical step must be checked to pass; a single miss sends you to remediation rather than an automatic fail.
If you miss a critical step, the instructor stops, reviews the error, and lets you retest, usually the same day. The AHA designs the test to confirm competency, not to weed people out. Most candidates who remediate pass on the second attempt after a quick coaching session.
The Megacode Testing Checklist comes in twelve scenarios that mix bradycardia, tachycardia, VF, PEA, asystole, and post-arrest care in different orders. You won't know which one you'll get. Learn the branches rather than memorizing one script and the order won't matter.
Timing is the hidden scoring layer in the Megacode. Rhythm checks happen every two minutes, and each check, with or without a pulse check, should take no more than ten seconds. Epinephrine repeats every three to five minutes, which means roughly every other cycle. Instructors count. If you call for a rhythm check at 45 seconds or forget epinephrine for eight minutes, it shows up on the sheet. Practicing with a visible clock fixes this faster than any amount of reading.
That's why so many candidates search for an ACLS timer app before their session. There are dedicated code-timer apps that beep at two-minute intervals and track drug times, and the AHA's own Full Code Pro app documents events in real time. During the actual test you'll usually assign a team member as timekeeper and recorder, which is itself a checklist item. Work through the acls vfib algorithm with a timer running so the rhythm of CPR, check, shock, drug becomes physical memory.
Drug timing is the other trap. Know that the first dose of amiodarone acls providers give is 300 mg after the third shock, and the second is 150 mg. Atropine repeats every three to five minutes. Adenosine for stable narrow-complex tachycardia is 6 mg followed by 12 mg. Reading acls rhythm strips quickly is what makes those decisions possible within the ten-second window.
Instructors see the same mistakes every session. The biggest one is going quiet. The Megacode scores what you say as much as what you do, and a team leader who thinks silently gets no credit for the thinking. Verbalize the rhythm, the intervention, and the reason. The second is shocking a non-shockable rhythm, usually because the candidate saw a wide complex and panicked. Slow down for the ten-second check and name the rhythm before touching the defibrillator.
Drug errors come next. Candidates mix up amiodarone and lidocaine doses, give atropine 0.5 mg from old guidelines, or forget the epinephrine interval entirely. Review the aha acls algorithms the night before and keep a mental list of the doses. Knowing the full set of acls drugs with routes and repeat timing is the single highest-yield thing you can study for the Megacode.
Then there's the BLS station, which humbles experienced clinicians who haven't done compressions in years. Shallow depth, incomplete recoil, and pauses over ten seconds are all flagged by the feedback manikin. The 18-second cycle is tighter than it sounds. Finally, watch the post-arrest steps. Many people relax once ROSC is called and forget the 12-lead, the oxygen target, and temperature management. The checklist doesn't end until the patient is stable.
Print the checklists and use them as scripts. Read the BLS sheet aloud while you mime each action, then time yourself doing 30 compressions and 2 breaths on a pillow or a couch cushion. It feels silly. It also builds the muscle memory that keeps you under 18 seconds when a stranger with a stopwatch is watching. For the Megacode, record yourself running each branch as team leader and play it back. You'll hear the pauses and the missing verbalizations immediately.
Study partners help more than videos. Have someone read a scenario, change the rhythm every two minutes, and tick the checklist boxes as you call interventions. Swap roles so you also learn what a good compressor and recorder sound like. If you're taking the blended route to acls certification online, the Part 1 simulated cases are a decent stand-in, but they don't replace saying the words with your voice.
Finally, get your hands on real equipment if you can. Hospitals often let staff practice on training manikins, and many centers that list acls classes near me will let you book an extra practice hour for a small fee. Ten minutes with a bag-mask and a feedback manikin is worth an hour of reading. Then spend the night before on drug doses and rhythm recognition, not on re-reading the whole manual.
Once the instructor checks the last box, you get an AHA ACLS Provider eCard, usually within a day or two of the training center processing the roster. It's valid for two years from the issue date. Employers verify it through the AHA eCard lookup, so keep the claim email. If you remediated and passed on the second attempt, nothing on the card says so. A pass is a pass.
Plan your acls renewal well before the expiration month. The update course is shorter than the initial provider course, but it uses the same skills checklists, so you'll do the BLS test and a Megacode again. Most people find the renewal Megacode harder than they expected because two years of routine work erodes drug-dose recall. A week of review fixes that. Many centers now offer acls recertification online through the HeartCode blended path, with only the skills portion done in person.
Beyond the card itself, the skills you just proved carry over. PALS uses the same testing structure with pediatric scenarios, and many nurses and paramedics take both within the same year. If you plan to work in critical care, emergency medicine, or anesthesia, an unexpired ACLS card is a baseline expectation rather than a bonus. Knowing the checklist means you can maintain it with minimal stress every two years.
The AHA publishes the Adult High-Quality BLS Skills Testing Checklist and the Megacode Testing Checklists in the ACLS Instructor Manual and on the instructor network. Training centers may share them with students, and the current sheets appear in the ACLS Provider Manual appendices as well. Ask your instructor for the exact version they use. The 2020 guidelines are still the basis for testing, with focused updates folded in, and the critical steps haven't changed in ways that affect a well-prepared candidate.
Don't confuse the ACLS checklist with a physical therapy ACL rehab checklist, which shows up in the same search results constantly. Nothing in this article is about knees. If you're comparing ACLS with pediatric certification, the aha acls and PALS courses share the checklist format, so preparing for one makes the other far easier. The BLS test is identical across both.
Beyond official materials, practice questions are the fastest way to check your recall. Our airway management and ventilation quizzes on this page mirror the questions instructors ask at the airway station, and the rhythm and pharmacology sets cover the Megacode branches. Work through them with the checklist beside you and note which critical steps you can't explain. Those are the ones to drill on a manikin.
Treat the check off as a performance with a known script rather than a mystery exam. The AHA tells you what's on the sheet. Your job is to execute it under mild pressure while a stranger watches, which is honestly good practice for a real code. Rehearse out loud, keep a timer running, and know your doses cold. If you can list the Hs and Ts and the shockable rhythms without hesitation, the Megacode becomes a conversation with your team instead of a test.
Give yourself at least a week of review, more if it's been years since your last course. Spend the first few days on rhythm recognition and pharmacology, the middle on running scenarios with a partner, and the last day on the BLS mechanics and the airway adjuncts. Don't cram the manual the night before. Sleep matters more than one more read-through, and the skills session will punish shaky hands faster than it punishes a missed detail you can verbalize your way out of.
Then walk in early, ask to see the checklist, and use the practice stations for real repetitions. Most instructors want you to pass and will coach you through weak spots during Part 2 before anything is scored. Use that. When testing starts, narrate, keep compressions going, and check the clock every two minutes. Do those three things and the clipboard will fill up with check marks.