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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