Skill Checklists
Pre and Post-Op
Name
Email
LAST 4 OF SSN
This checklist was electronically signed on (Today’s date)
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
General OR
CVOR
Outpatient
Trauma
Peds-General OR
Peds-CVOR
First Assist
Scrub Experience
Abdominal Perineal Resection
Appendectomy/Cholescystectomy
Breast Biopsy
Colon Resection/Surgery
Gastrectomy
Gastric Bypass/Roux-en-Y
Hemorrhoidectomy
Herniorrhaphy - Inguinal, Ventral, Femoral, Umbilical
Laparoscopic General Surgeries
Laparoscopic Nissen Fundoplication
Mastectomy
Splenectomy
Thyroidectomy
Scrub General Surgery
Anal Fistulectomy/Anoplasty
Appendectomy/Cholecystectomy
Biopsy (Mass, Muscle, Lymph Node)
Bronchoscopy
Colostomy
Esophagogastroduodenoscopy w/ Biopsy
Esophagoscopy
Exploratory Laparotomy
Flexible Sigmoidoscopy
Fundoplication
Gastrostomy
Herniorrhaphy
Insertion of Port-a-Cath, Hickman, Broviac
Laparascopic General Surgery Procedures
Liver Biopsy
Percutaneous Endoscopic Gastrostomy
Thoracoscopy/Nuss Procedure
Scrub Peds General Surgery
Aorta Repair
Aorto-Bifemoral/Femoral-Pop Bypass Graft
Cardiac Bypass Surgery
Carotid Endarterectomy
Endoscopic Vascular Procedures
Femoral Popliteal Bypass Graft
Laparascopic Cardiac Surgery
Robotic Assisted Cardiac Surgery
Valve Replacement/Repair
Ventricular Assist Device
Scrub CV Surgery
Endoscopic Thoracic Procedures
Esophagoogastrectomy
Mediastinotomy/Sternotomy
Thoracotomy
Scrub Thoracic Surgery
Total Joint Replacement
Closed Reduction of Fracture
External Fixator
Cannulated Hip Screws
Bankhart Procedure
Birmingham Procedure
Carpal Tunnel Release
Arthroscopy
Anterior Cruciate Ligament Reconstruction
Open Reduction Internal Fixation
Scrub Orthopedics
Craniotomy
Steriotactic Guided Brain Biopsy
Laminectomy
Laparoscopic Anterior Laminectomy
Insertion of Vagal Nerve Stimulator
Insertion of VP Shunt
Spinal Fusion
Anterior Cervical Discectomy with Fusion
Posterior Cervical Laminectomy
Scrub Neurological Surgery
Vasicaurethropexy
Marshall Marchetti
Circumcision
Cystoscopy/Cystogram/Pyelogram
Prostatectomy
Nephrectomy
Orchidectomy/Orchidopexy
Ureterostomy
Laparoscopic Assisted GU Procedures
Robotic Assisted GU Procedures
Scrub GU Surgery
Hydrocelectomy
Repair of Hypospadias
Retrograde Pyelogram
Scrub Peds GU
Abdominal Hysterectomy
Anterior Posterior Repair
C-Section
D AND C
Laparoscopic Assisted Hysterectomy
Laparotomy with Microtuboplasty
Robotic Assisted GYN Procedures
Vaginal Delivery
Vaginal Hysterectomy
Scrub Gyn Surgery
Endoscopic ENT Procedures
Laryngectomy
Mastoidectomy
Myringotomy with Insertion of Tubes
Radical Neck
Septoplasty
Tonsillectomy And Adenoidectomy
Tracheostomy
Tympanoplasty
Scrub ENT Surgery
Cochlear Implant
Laryngotracheoplasty
Myringotomy with Tubes
Suspension Microlaryngoscopy
Turbinate Reduction
Tympanoplasty/Typanomastoidectomy
Scrub Peds ENT
Craniectomy
Craniofacial Reconstruction
Dental Surgery
Leforte 1 Maxillary/Sagittal Osteotomy
ORIF Mandibular Fracture
Otoplasty
Reconstruction of Ear
Removal of Arch Bars
Rhinoplasty
Scrub Craniofacial/Oral
Blephoroplasty
Breast Reconstruction with Implant
Breast Reduction Mammoplasty
Face Lift
Mastectomy with Tram Flap Reconstruction
Split Thickness Skin Graft
Suction Lipectomy
Heart
Lungs
Liver
Pancreas
Eye
Organ donation
Scrub transplants
Cataract Extraction with Implant
Vitrectomy
Scleral Buckle
Cataract Aspiration; Anterior Vitrectomy
Corneal Transplant
Scrub Ophthalmology
Dacrocystorhinostomy
Excision of Chalazion
Eye Muscle Surgery
Levator Resection
Orbitotomy of Eye
Repair of Ptosis
Scrub Peds Opthalmology
Scrub Peds Neuro
Arterial Switch
ASD/VSD Repair
Atrial Septectomy
Bidirectional Glenn
BT Shunt
ECMO Insertion/Decannulation (Cardiac)
Fontan Procedure
Norwood Procedure
Pacemaker
PDA Ligation
Repair of Coarctation of Aorta
Ross Procedure
Tetralogy of Fallot Repair
Valve Repair/Replacement
Scrub Peds Cardiac/Vascular
Kidney
Liver/Pancreas
Lung
Organ Donation
Scrub Peds Transplant
Mandibular Osteotomy
Repair of Cleft Lip, Nose, Palate
Skin Graft
Scrub Peds C-Fl/Oral/Plastics
Acetabuloplasty/Triple Innominate
Arthroscopy of Knee, Wrist, Shoulder
Closed Reduction, Percutaneous Pin
External Fixator (Ilizarov/Orthofix)
ORIF Shoulder, Humerus, Tibia, Femur
Osteotomy/VDRD/Calcaneal/Metatarsal
Spinal Fusion/Spinal with Instrumentation
Tendoachilles Lengthening
Scrub Peds Ortho
Electrocautery (ESU)
Laparoscopy Systems
Neuro
OR Fracture Tables (List Types)
Orthopedic Total Joint Systems
Power Equipment
Spinal Fusion Instrumentation
Robotics Systems (List types)
Malignant Hyperthermia Protocol
Administer and Monitor Moderate Sedation
Universal Protocol for Wrong Site Surgery
National Patient Safety Goals/Core Measures
Fall Risk Assessment/Prevention
Pressure Ulcer Risk Assessment/Prevention
Restraints/Use of Least Restrictive Device
Age Specific/Population-Based Care
Isolation Precautions
Infection Prevention
Epic
Cerner
Eclipsys
McKesson
Meditech
Other Computerized System
Computerized Physician Order Entry
EMR Conversion
BLS
5
NRP
PALS
Certified Nurse Operating Room
Registered Nurse First Assist
Other: Specify:
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.
