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.
| IV Therapy | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| Start peripheral IV - angio cath |
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| IV Therapy - Assist with: | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| Insertion of A-lines |
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| Insertion of CVP - jugular |
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| Insertion of CVP - sublavian |
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| Insertion of Swan-Ganz |
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| Drawing blood from central line |
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| Drawing venous blood |
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| Administration of blood and products | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| Packed red blood cells |
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| Plasma/Albumin |
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| Whole blood |
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| General Surgery | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| Abdominal perineal resection |
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| Adrenalectomy |
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| Anal fissurectomy |
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| Appendectomy |
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| Bowel resection |
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| Breast biopsy |
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| Cholecystectomy (open) |
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| Colectomy |
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| Colostomy/ileostomy |
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| Esophogeal resection |
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| Exploratory laparotomy |
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| Gastrectomy |
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| Gastroplasty |
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| Hemorrhoidectomy |
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| Hemicolectomy |
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| Hepatic resection |
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| Herniorrhaphy - femora |
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| Herniorrhaphy - inguina |
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| Herniorrhaphy - umbilical |
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| Herniorrhaphyhiatal transabdominal/transthoracic |
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| Hiatal hernia repair |
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| Hepatic resection |
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| Insertion - Hickman |
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| Insertion - Groshong |
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| Insertion - Portacath |
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| Hydroceletomy |
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| Imperforate anus reconstruction |
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| Lumbar sympathectomy |
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| Omphalocele repair |
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| Pancreatectomy / pancreatogram |
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| Pilonidal cystectomy |
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| Portal caval shunt |
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| Pyloric stenosis |
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| Radical mastectomy |
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| Saphenous vein ligation and stripping |
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| Sentinel node biopsy |
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| Splenectomy |
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| Tenchknoff duct cyst excision |
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| Thyroglossal duct cyst excision |
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| Thryoidectomy |
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| Vagotomy |
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| Thoracic and Open Heart | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| Cervical rib excision |
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| Chamberlain procedure |
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| Closed thoracotomy |
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| Correction pectus excavatum |
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| Esophagectomy |
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| Heller procedure |
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| Mitral commissurotomy |
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| Mitral or aortic valve replacement |
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| IAPB insertion |
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| CABG |
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| Cardiac valve replacement |
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| Patent ductus arteriosus repair |
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| Septal defect repairs |
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| Pacemaker implanation - endocardial |
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| Pacemaker implanation - myocardia |
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| Pacemaker - temporary |
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| Pericardiectomy |
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| Pericardial window |
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| Resection coarctation aorta |
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| Portocaval shunt |
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| Tetrology of fallot |
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| Thoracoplasty |
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| Tracheal resection |
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| Transthoracic diaphragmatic heniorrhaphy |
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| Vascular | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| A-V access graft |
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| Aortic aneurysm with graft replacement |
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| Endarterectomy/carotid - femoral |
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| Fem-pop bypass |
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| Peripheral vascular bypass procedures |
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| Resection carotid aneurysm with graft |
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| Thrombectomy/embolectomy |
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| Vena cava filter/umbrella |
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| Vena cava ligation |
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| Neurology | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| A-V malformation |
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| Anterior cervical fusion |
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| Anterior laparoscopic spine procedures |
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| Anterior lumbar interbody fusion (ALIF) |
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| Burr holes for subdural hematoma |
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| Carotid ligation |
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| Cervical sympathectomy |
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| Craniectomy for decompression fracture |
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| Discetomy |
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| Hypophysectomy |
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| Insertion nerve stimulators |
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| Insertion medication pumps |
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| Laminectomy |
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| Myelomeningocele repair |
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| Pedicle screw insertion |
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| Posterior lumbar interbody fusion (PLIF) |
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| Shunt procedure/VP, VA/LP |
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| Spine fusion |
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| Ulnar nerve transfer |
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| Ventriculography / ventriculoscopy |
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| Ventriculostomy |
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| Neurology - Cranioplasty/craniotomy | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| Clipping of aneurysm |
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| Tumor excision |
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| Stealth crainiotomy |
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| Urology | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| Adult circumcision |
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| Cystectomy |
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| Cystoscopy/ureteroscopy |
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| Hypospadias repair |
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| Ileal loop |
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| Implants - penile and testicular |
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| Lithotripsy |
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| Nephrectomy |
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| Nephrolithotomy |
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| Orchiopexy |
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| Prostatectomy - perineal |
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| Prostatectomy - supra-pubic |
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| Pyleoplasty |
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| Radical node dissection |
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| Scott incontinence device |
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| TURP |
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| Ureterolithotomy |
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| Vasectomy |
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| Vasovasostomy |
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| Waterhouse procedure |
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| Gynecology | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| Cesarean section |
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| Colpotomy |
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| Dilation and curettage (DandC) |
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| Hysterectomy - abdominal |
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| Hysterectomy - vaginal |
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| Marshall - Marchetti |
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| Marsupialization, Bartholin cyst |
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| Ovarian cystectomy |
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| Radium insertion |
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| Salpingo-oophorectomy |
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| Sacral spinus fixation |
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| Shirodkar procedure |
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| Suction curettage |
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| Termination of pregnancy |
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| Tubal ligation |
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| Vaginal recontruction |
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| Vaginectomy/vulvectomy |
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| Orthopedics | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| Acetabular/pelvic ORIF |
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| Achilles tendon repair |
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| Amputation- leg, arm |
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| Anterior cruciate ligament repair |
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| Application of external fixators - extremeties |
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| Application of external fixators - pelvis |
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| Application of halo traction |
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| Arthrotomy |
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| Bipolar/unipolar hips |
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| Bunionectomy |
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| Calcanel reconstruction |
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| Capsulorrhaphy |
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| Carpal tunnel release |
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| Closed reduction fracture |
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| Hand surgery with implants |
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| Harrington rod instrumentation and / or Dwyer procedure |
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| Heel cord lengthening |
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| Laminectomy |
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| Olecranon bursa, excision of |
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| ORIF, internal fixation with compression set |
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| Patellectomy |
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| PuttiPlatt/Bankart procedure/rotator cuff repair |
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| Reduction with compression sets |
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| Reimplanation of digits |
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| Repair hammer toes |
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| Sacro-iliac (SI) joint screws |
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| Sharrard procedure |
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| Spica cast, application |
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| Spinal fusion |
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| Tendon transplants (hand and foot) |
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| Orthopedics - Arthroscopy | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| Ankle |
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| Elbow |
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| Knee |
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| Shoulder |
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| Orthopedics - Hip compression nails and lag screws | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| Jewett |
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| Kuntscher rod |
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| Lottes |
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| Rush |
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| Schneider |
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| Zimmer |
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| Iliac crest bone graft |
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| Insertion Austin Moore hip prosthesis |
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| Orthopedics - Intramedullary rods | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| Extraction |
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| Femoral |
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| Humeral |
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| Insertion |
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| Supracondylar |
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| Tibal |
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| Orthopedics - Total joint replacements/revisions | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| Hip |
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| Knee |
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| Shoulder |
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| Plastics | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| Abdominal lipectomy |
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| Abdominalplasty |
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| Blepharoplasty |
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| Cleft lip repair |
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| Dermabrasion |
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| Face lift |
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| Mentoplasty |
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| Otoplasty |
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| Pedicle grafts |
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| Rhytidectomy |
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| Scar revisions |
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| Split thickness skin grafting |
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| Tissue expanders |
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| Plastics - Mammoplasty | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| Augmentation |
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| Reduction |
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| Tramflaps with reconstructive mammoplasty |
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| Ear, Nose and Throat | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| Adenoidectomy |
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| Caldwell - Luc |
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| Cleft lip/palate repair |
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| Closed reduction nasal fx |
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| Ethmoidectomy |
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| Excision of salivary gland tumor |
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| Fenestration procedure |
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| Frontal flap sinus procedure |
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| Glossectomy |
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| Laryngectomy |
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| Mandibulectomy |
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| Mastoidectomy |
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| Maxillary advancement with graft |
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| Maxillectomy |
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| Myringoplasty |
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| Myringotomy with PE tube insertion |
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| Nasal polypectomy |
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| Open reducation facial fx |
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| Open reducation nasal fx |
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| Parotidectomy |
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| Pharyngeal flap procedure |
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| Radical neck dissection |
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| Ranulectomy |
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| Rhinoplasty/septoplasty |
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| Selective osteotomy of maxilla/mandible |
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| Sinus endoscopy |
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| Sinusotomy |
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| Stapedectomy |
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| Submucous resection |
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| Tonsillectomy |
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| Tracheostomy |
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| Tympanoplasty |
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| Oral | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| Closed reducation facial fractures/wiring |
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| Excision odontoma |
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| Excision of deciduous teeth |
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| Extraction of impacted molars |
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| Fractured jaws, mandibular and zagomatic |
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| Ginivectomy |
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| LeFort osteotomies |
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| Maxillary procedure with graft |
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| Pediatric dentistry |
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| Sagittal osteotomy |
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| Temporomandibular (TMJ) with arthroplasty |
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| TMJ exploration |
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| Ophthalmology | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| Cataract extraction with IOL |
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| Corneal transplant |
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| Dacryocystectomy |
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| Eye enucleation |
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| Exicison of chalazion |
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| Canthotomy |
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| Correction of ectropian/entropian |
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| Enucleation |
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| Eye transplant |
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| Iridectomy |
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| Lacrimal duct probing |
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| Lid and muscle procedures |
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| Orbital implant |
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| Phaco emulsification |
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| Ptergium repair |
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| Recession resection |
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| Refractive keratoplasty |
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| Repair orbital blowout fracture |
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| Repair of retinal detachment |
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| Scleral buckle |
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| Vitrectomy |
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| Endoscopic Procedures | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| Bronchoscopy |
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| Colonscopy |
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| Culdoscopy |
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| Esophagoscopy |
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| Gastroscopy |
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| Hysteroscopy |
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| Laparoscopic procedures | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| Appendectomy |
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| Cholecystectomy / cholangiogram |
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| Colon resection |
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| Diagnostic |
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| Hernia repair |
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| Nissen fundoplication |
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| Salpingo-oophorectomy |
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| Tubal ligation |
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| Vaginal hysterectomy |
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| Larynoscpy and microlaryngoscopy |
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| Mediastinoscopy |
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| Pelviscopy |
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| Sigmoidoscopy |
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| Thoracoscopy |
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| Transplant | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| Bone |
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| Bone marrow |
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| Corneal transplant |
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| Harvesting |
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| Heart |
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| Kidney |
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| Liver |
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| Lung |
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| Multi-organ |
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| Pancreas |
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| Skin |
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| Trauma | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| Burns |
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| Motor vehile accidents (multiple injuries) |
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| Traumatic amputations |
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| Trauma - Gunshot/stab wounds | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| Abdomen |
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| Chest |
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| Head |
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| Equipment | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| Argon beam coagulator |
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| Bair hugger |
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| Blood/fluid warmer |
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| Cardiac monitor and pacemaker |
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| Cell saver |
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| Cidex soak |
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| Cry-opthalmic unit |
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| Defibrillator/pacer |
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| Electrosurgical unit |
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| Emerson thoracic pump |
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| ETO sterilizer |
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| Eye magnet |
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| Fiber optic luminator |
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| Flash autoclave |
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| Hypo/hyperthemia units |
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| Kreiselman resuscitor |
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| Mesh graft |
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| MicroscopesNerve stimulatorNitrous oxide bank |
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| Nitrous oxide bank |
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| Ohio suction units |
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| Orthopedic arm board with drain |
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| Pleurevac disp. chest drainage |
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| Pneumatic tourniquet |
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| Sterad machine |
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| Steri-vac aeratopm cabinet |
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| Steris unit |
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| Tele therometer |
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| Ultrasonic cleaner |
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| Vac-pac positioner |
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| Vacuum curettage |
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| Washer sanitizer |
|
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| Washer sterilizer |
|
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| Equipment - Fracture tables | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| Chick/Marquet tables |
|
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| Jackson table |
|
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| Rush/Skytron tables |
|
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| Equipment - Intestinal stapling devices | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| EEA |
|
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| GIA |
|
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| LDS |
|
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| TA |
|
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| Equipment - Laser | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| CO2 |
|
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| Eye magnet |
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| Yag |
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| Other |
|
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| Camera/video systems | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| Camera controller |
|
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| Light source |
|
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| Printers |
|
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| VCRs |
|
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| Dermatome | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| Brown |
|
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| Padgett |
|
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| Zimmer |
|
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| Disposable grounding pads |
|
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| Drills | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| 3-M maxi driver |
|
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| Codman craniotome |
|
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| Hall air-driver |
|
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| Hall dental |
|
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| Hall neurotome |
|
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| Midax Rex/Anspach |
|
||||||
| Minidriver |
|
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| Stryker drills - large battery |
|
||||||
| Stryker drills - small battery |
|
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| Surgairtome |
|
||||||
| Synthes A-O drill |
|
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| Electrosurgical unit |
|
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| Miscellaneous | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| Assist with intubation |
|
||||||
| Conscious sediation administration |
|
||||||
| Conscious sediation monitoring |
|
||||||
| Management of malignant hypertensive crisis |
|
||||||
| Able to assure a safe environment for the specific needs of various age groups | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| A.Newborn/Neonate (birth - 30 days) |
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| B.Infant (30 days - 1 year) |
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| C.Toddler (1 - 3 years) |
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| D.Preschooler (3 - 5 years) |
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| E.School age children (5 - 12 years) |
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| F.Adolescents (12 - 18 years) |
|
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| G.Young adults (18 - 39 years) |
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| H.Middle adults (39 - 64 years) |
|
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| I.Older adults (64+) |
|
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