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.
| WORKSETTING | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| General OR |
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| CVOR |
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| Outpatient |
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| Trauma |
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| Peds-General OR |
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| Peds-CVOR |
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| First Assist |
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| Scrub Experience |
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| GENERAL SURGERY | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| Abdominal Perineal Resection |
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| Appendectomy/Cholescystectomy |
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| Breast Biopsy |
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| Colon Resection/Surgery |
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| Gastrectomy |
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| Gastric Bypass/Roux-en-Y |
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| Hemorrhoidectomy |
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| Herniorrhaphy - Inguinal, Ventral, Femoral, Umbilical |
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| Laparoscopic General Surgeries |
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| Laparoscopic Nissen Fundoplication |
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| Mastectomy |
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| Splenectomy |
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| Thyroidectomy |
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| Scrub General Surgery |
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| CARDIOVASCULAR | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| Aorta Repair |
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| Aorto-Bifemoral/Femoral-Pop Bypass Graft |
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| Cardiac Bypass Surgery |
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| Carotid Endarterectomy |
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| Endoscopic Vascular Procedures |
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| Femoral Popliteal Bypass Graft |
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| Laparascopic Cardiac Surgery |
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| Robotic Assisted Cardiac Surgery |
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| Valve Replacement/Repair |
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| Ventricular Assist Device |
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| Scrub CV Surgery |
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| THORACIC | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| Endoscopic Thoracic Procedures |
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| Esophagoogastrectomy |
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| Mediastinotomy/Sternotomy |
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| Thoracoscopy/Nuss Procedure |
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| Thoracotomy |
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| Scrub Thoracic Surgery |
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| ORTHOPEDIC | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| Total Joint Replacement |
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| Closed Reduction of Fracture |
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| External Fixator |
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| Cannulated Hip Screws |
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| Bankhart Procedure |
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| Birmingham Procedure |
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| Carpal Tunnel Release |
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| Arthroscopy |
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| Anterior Cruciate Ligament Reconstruction |
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| Open Reduction Internal Fixation |
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| Scrub Orthopedics |
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| NEUROLOGICAL | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| Craniotomy |
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| Steriotactic Guided Brain Biopsy |
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| Laminectomy |
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| Laparoscopic Anterior Laminectomy |
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| Insertion of Vagal Nerve Stimulator |
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| Insertion of VP Shunt |
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| Spinal Fusion |
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| Anterior Cervical Discectomy with Fusion |
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| Posterior Cervical Laminectomy |
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| Scrub Neurological Surgery |
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| GENITOURINARY | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| Vasicaurethropexy |
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| Marshall Marchetti |
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| Circumcision |
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| Cystoscopy/Cystogram/Pyelogram |
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| Prostatectomy |
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| Nephrectomy |
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| Orchidectomy/Orchidopexy |
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| Ureterostomy |
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| Laparoscopic Assisted GU Procedures |
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| Robotic Assisted GU Procedures |
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| Scrub GU Surgery |
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| GYNECOLOGICAL | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| Abdominal Hysterectomy |
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| Anterior Posterior Repair |
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| C-Section |
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| D & C |
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| Laparoscopic Assisted Hysterectomy |
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| Laparotomy with Microtuboplasty |
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| Robotic Assisted GYN Procedures |
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| Vaginal Delivery |
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| Vaginal Hysterectomy |
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| Scrub Gyn Surgery |
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| EAR/NOSE/THROAT | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| Endoscopic ENT Procedures |
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| Laryngectomy |
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| Mastoidectomy |
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| Myringotomy with Insertion of Tubes |
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| Radical Neck |
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| Septoplasty |
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| Tonsillectomy & Adenoidectomy |
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| Tracheostomy |
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| Tympanoplasty |
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| Scrub ENT Surgery |
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| CRANIOFACIAL/ORAL | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| Craniectomy |
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| Craniofacial Reconstruction |
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| Dental Surgery |
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| Leforte 1 Maxillary/Sagittal Osteotomy |
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| ORIF Mandibular Fracture |
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| Otoplasty |
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| Reconstruction of Ear |
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| Removal of Arch Bars |
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| Repair of Cleft Lip, Nose, Palate |
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| Rhinoplasty |
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| Scrub Craniofacial/Oral |
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| PLASTIC | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| Blephoroplasty |
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| Breast Reconstruction with Implant |
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| Breast Reduction Mammoplasty |
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| Face Lift |
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| Mastectomy with Tram Flap Reconstruction |
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| Split Thickness Skin Graft |
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| Suction Lipectomy |
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| Scrub Plastics |
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| TRANSPLANTS | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| Heart |
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| Lung |
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| Liver |
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| Pancreas |
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| Eye |
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| Organ Donation |
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| Scrub Transplants |
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| OPHTHALMOLOGY | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| Cataract Extraction with Implant |
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| Vitrectomy |
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| Scleral Buckle |
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| Cataract Aspiration; Anterior Vitrectomy |
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| Corneal Transplant |
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| Scrub Ophthalmology |
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| GENERAL SURGERY | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| Anal Fistulectomy/Anoplasty |
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| Appendectomy/Cholecystectomy |
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| Biopsy (Mass, Muscle, Lymph Node) |
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| Bronchoscopy |
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| Colostomy |
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| Esophagogastroduodenoscopy w/ Biopsy |
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| Esophagoscopy |
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| Exploratory Laparotomy |
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| Flexible Sigmoidoscopy |
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| Fundoplication |
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| Gastrostomy |
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| Herniorrhaphy |
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| Insertion of Port-a-Cath, Hickman, Broviac |
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| Laparascopic General Surgery Procedures |
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| Liver Biopsy |
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| Percutaneous Endoscopic Gastrostomy |
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| Thoracoscopy/Nuss Procedure |
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| Scrub Peds General Surgery |
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| GENITOURINARY | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| Circumcision |
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| Cystoscopy/Cystogram/Pyelogram |
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| Hydrocelectomy |
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| Nephrectomy |
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| Orchidectomy/Orchidopexy |
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| Repair of Hypospadias |
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| Retrograde Pyelogram |
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| Ureterostomy |
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| Scrub Peds GU |
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| NEURO | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| Craniotomy |
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| Insertion of Vagal Nerve Stimulator |
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| Insertion of VP Shunt |
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| Laminectomy |
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| Scrub Peds Neuro |
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| CARDIAC/VASCULAR | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| Arterial Switch |
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| ASD/VSD Repair |
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| Atrial Septectomy |
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| Bidirectional Glenn |
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| BT Shunt |
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| ECMO Insertion/Decannulation (Cardiac) |
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| Fontan Procedure |
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| Norwood Procedure |
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| Pacemaker |
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| PDA Ligation |
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| Repair of Coarctation of Aorta |
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| Ross Procedure |
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| Tetralogy of Fallot Repair |
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| Valve Repair/Replacement |
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| Ventricular Assist Device |
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| Scrub Peds Cardiac/Vascular |
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| TRANSPLANT | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| Heart |
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| Kidney |
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| Liver/Pancreas |
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| Lung |
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| Organ Donation |
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| Scrub Peds Transplant |
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| OPHTHALMOLOGY | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| Corneal Transplant |
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| Dacrocystorhinostomy |
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| Excision of Chalazion |
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| Eye Muscle Surgery |
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| Levator Resection |
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| Orbitotomy of Eye |
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| Repair of Ptosis |
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| Scrub Peds Opthalmology |
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| EAR/NOSE/THROAT | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| Cochlear Implant |
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| Laryngotracheoplasty |
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| Myringotomy with Tubes |
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| Septoplasty |
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| Suspension Microlaryngoscopy |
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| Tonsillectomy & Adenoidectomy |
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| Tracheostomy |
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| Turbinate Reduction |
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| Tympanoplasty/Typanomastoidectomy |
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| Scrub Peds ENT |
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| CRANIOFACIAL/ORAL/PLASTICS | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| Craniectomy |
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| Craniofacial Reconstruction |
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| Dental Surgery |
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| Leforte 1 Maxillary/Sagittal Osteotomy |
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| Mandibular Osteotomy |
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| ORIF Mandibular Fracture |
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| Otoplasty |
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| Reconstruction of Ear |
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| Repair of Cleft Lip, Nose, Palate |
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| Rhinoplasty |
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| Skin Graft |
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| Scrub Peds C-Fl/Oral/Plastics |
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| ORTHOPEDICS | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| Acetabuloplasty/Triple Innominate |
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| Arthroscopy of Knee, Wrist, Shoulder |
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| Closed Reduction, Percutaneous Pin |
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| External Fixator (Ilizarov/Orthofix) |
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| ORIF Shoulder, Humerus, Tibia, Femur |
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| Osteotomy/VDRD/Calcaneal/Metatarsal |
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| Spinal Fusion/Spinal with Instrumentation |
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| Tendoachilles Lengthening |
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| Scrub Peds Ortho |
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| OR EQUIPMENT | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| Electrocautery (ESU) |
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| Laparoscopy Systems |
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| Neuro |
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| OR Fracture Tables (List Types) |
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| Orthopedic Total Joint Systems |
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| Power Equipment |
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| Robotics Systems (List types) |
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| Spinal Fusion Instrumentation |
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| PROFESSIONAL KNOWLEDGE AND SKILLS | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| Malignant Hyperthermia Protocol |
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| Administer and Monitor Moderate Sedation |
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| Universal Protocol for Wrong Site Surgery |
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| National Patient Safety Goals/Core Measures |
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| Fall Risk Assessment/Prevention |
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| Pressure Ulcer Risk Assessment/Prevention |
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| Restraints/Use of Least Restrictive Device |
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| Age Specific/Population-Based Care |
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| Isolation Precautions |
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| Infection Prevention |
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| EMR | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| Epic |
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| Cerner |
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| Eclipsys |
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| McKesson |
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| Meditech |
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| Other Computerized System |
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| Computerized Physician Order Entry |
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