Operating-room Skills Checklist

SKILLS CHECKLIST

Operating Room

Name*

Telephone*

Who is your recruiter?*

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 : -	1 = Never Performanced	2 = Limited Experience	3 = Comfortable Performing	4 = Proficient
Frequency : -	1 = Never	2 = Sometimes	3 = Often	4 = Always

GENERAL SURGERY Proficiency

Frequency

Abdominal Perineal Resection

Adrenalectomy

Anal Fissurectomy

Appendectomy

Breast Biopsy

Central Line Insertion

a. Hickman

b. Groshong

c. Portacath

Cholecystectomy/cholangiogram

Colectomy

Colon Resection

Colostomy/Ileostomy

Gastrectomy

Hemorrhoidectomy

Hepatic Resection

Herniorrhaphy

a. Inguinal

b. Umbilical

Hiatal Herniorrhaphy

a. Transabdominal

b. Transthoracic

Hydrocelectomy

Imperforate anus reconstruction

Lumbar sympathectomy

Omphalocele repair

Pancreatectomy/pancreatogram

Pilonidal cyctectomy

Portal caval shunt

Pyloric stenosis

Radical mastectomy

Saphenous vein ligation & stripping

Splenectomy

Tenchkhoff catheter placement

Thyroglossal duct cyst excision

Thyroidectomy

Vagotomy

Whipple (Open)

ENDOSCOPIC PROCEDURES Proficiency

Frequency

Bronchoscopy

Colonscopy

Cystoscopy

Gastroscopy

Hyteroscopy

Laparoscopy

a. Appendectomy

b. Cholecystectomy

c. Cholangiogram

d. Colon Resection

e. Herniorrhaphy

f. Nissen Fundoplication

g. Pelvic Exoneration

h. Salpingooophorectomy

i. Tubal Ligation

j. Scope Assisted Vaginal Hysterectomy

Laryngoscopy & Microlaryngoscopy

Mediastinoscopy

Pelviscopy

Sigmoidoscopy

Thoracoscopy

GYNECOLOGY Proficiency

Frequency

Cesarean Section

Colpotomy

D & C

Ectopic Pregnancy

Hysterectomy

a. Abdominal

b. Vaginal

Marshall-Marchetti

Marsupialization-Bartholin Cyst

Ovarian Cystectomy

Radium Insertion

Sacral Spinus Fixation

Salpingoplasty

Shirodkar Procedure

Suction Curettage

Vaginal Reconstruction

Vaginectomy

Vulvectomy

NEUROLOGY Proficiency

Frequency

A-V malformation

Anterior cervical fusion

Anterior laparoscopic spine procedures

Anterior lumbar interbody fusion (ALIF

Burr holes for subdural hematoma

Carotid ligation

Cervical Fusion

a. Anterior

b. Posterior

Cervical Sympathectomy

Cervical Fusion

a. Aneurysm Clipping

b. Tumor Excison

b. Stealth

Craniectomy for Decompression Fx

Crutchfield Tong Insertion

Discectomy

Hypophysectomy

Medication Pump Insertion

Myelomeningocele repair

Nerve Stimulator Insertion

Pedicle screw insertion

Posterior lumbar interbody fusion(PLIF)

Shunt procedure/VP,VA/LP

Ulnar nerve transfer

Ventriculography

Ventriculostomy

OPHTHALMOLOGY Proficiency

Frequency

Cataract Extraction with IOL

Corneal Transplant

Dacryocystectomy

Dacryocystorhinostomy

Iridectomy

Lid and Muscle Procedures

Orbital Implant

Phaco Emulsificatin

Pterygium Repair

Recession Resection

Repair Orbital Blowout Fracture

Scleral Buckle

Vitrectomy

ORAL Proficiency

Frequency

Closed reduction facial fractures/wiring

Excision odontoma

Extraction of deciduous teeth

Extraction of impacted molars

Fractured jews, mandibular and zagomatic

LeFort osteotomies

Maxillary procedure with graft

Pediatric dentistry

Sagittal osteotomy

Temporomandibular joint (TMU) with arthroplasty

TMU exploration

OTORHINOLARYNGOLOGIC Proficiency

Frequency

Adenoidectomy

Caldwell-Luc

Cleft Lip/Palate Repair

Closed Reduction Nasal Fracture

Ethymoidectomy

Excision Salivary Gland Tumor

Fenestration

Frontal Flap Sinus

Glossectomy

Laryngectomy

Mandibulectomy

Mastoidectomy

Maxillary Advancement/Hip Graft

Maxillectomy

Myringoplasty w/ PE Tube Insertion

Nasal Polypectomy

Open Reduction

a. Facial Fractures

b. Nasal Fractures

Parotidectomy

Pharyngeal Flap

Radical Neck Dissection

Ranulectomy

Rhinoplasty/Septoplasty

Selective Osteotomy

a. Maxilla

b. Mandible

Sinus Endoscopy

Sinusotomy

Stapedectomy

Submucous Resection

Tonsillectomy

Tracheostomy

Tympanoplasty

ORTHOPEDICS Proficiency

Frequency

Acetabular/peivic QRIF

Achilles tendon repair

Anterior cruciate ligament repair

Application of halo traction

Arthrotomy

Arthroscopy

a. Ankie

b. Elbow

c. Knee

d. Shoulder

Bipolar/unipolar hips

Bunionectomy

Calcaneal reconstruction

Capsulorrhaphy

Carpal tunnel release

Closed reduction fracture

Extremily Amputation

External Fixator Application

a. Extremities

b. Peivis

Halo Traction Application

Hammer Toe Repair

Hand surgery

Harrington rod insertion

Heel cord lengthening

Hip compression nails & leg screws

a. Jewett

b. Kuntscher rod

c. Lotters

d. Rush

e. Schneider

f. Zimmer

g. Other - list:

Hip Prothesis Insertion

Iliac crest bone graft

Intramedullary rods

a. Femoral

b. Humeral

c. Supracondylar

d. Tibial

Laminectomy

Olecranon bursa, excision of

Reduction with compression sets

Reimplantation of digits

a. Putti Platt

b. Bankart

Sacro-iliac (ST) joint screws

Spice cast, application of

Spinal Fusion

a. Anterior

b. Posterior

Tendon transplants (hand & foot)

Total joint replacements

a. Hip

b. Knee

c. Shoulder

TRANSPLANT Proficiency Frequency

Bone

Bone marrow

Corneal

Harvesting

Heart

Kidney

Liver

Lung

Multi-organ

Pancreas

Skin

TRAUMA Proficiency Frequency

Burns

Multiple Injury Accidents

Gunshot/Stab wounds

a. Abdomen

b. Chest

c. Head

UROLOGY Proficiency Frequency

Adult circumcision

Bladder Suspension

Cystectomy

Hypospadias repair

Impiants; pencile, testicular

Litotripsy

Nephrectomy

Nephrolithotomy

Orchiopexy

Waterhouse procedure

Pyeioplasty

Radical node dissection

Scott incontinence device

TURP

Ureterolithotomy

Vasectomy

Vasovasostomy

Prostatectomy

a. Perineal

b. Supra-pubic

SKILLS/PROCEDURES


	Never Performed	Limited Experience	Comfortable Performing	Proficient
Blood/Blood Product Infusion
a. Packed RBCs

b. Whole Blood

b. Chest

Blood Gas Interpretation

Chest Tube & Drainage System

Foley Catheter Insertion & Care

a. Female

b. Male

Gastric Suction

Phlebotomy

a. Venous Blood Draw

b. Central Line Blood Draw

Restraints

Intubation

Extubation

Hemodynamic Monitoring Noninvasive

a. Ausculation

b. Electronic

Intravenous Therapy

a. Angiocath Insertion

b. A-Line Insertion (assist)

c. CVP Insertion (assist)

d. Swan-Ganz Insertion (assist)

Malignant Hyperthermia Crisis

a. Assessment

b. Management

Oxygen Therapy Administration

a. Face Mask

b. Nasal Cannula

c. Trach Collar

SKILLS/PROCEDURES


	Never Performed	Limited Experience	Comfortable Performing	Proficient
Suctioning
a. Nasopharyngeal

b. Oropharyngeal

c. Tracheostomy

Temperature

a. Axillary

b. Oral

c. Rectal

d. Tympanic

Wound Care

a. Incisional Dressing Assessment

b. Surgical Wounds with Drains

Knowledge of Medications

Knowledge of Emergency Meds

Patient Teaching

EQUIPMENT & SUPPLIES


	Never Performed	Limited Experience	Comfortable Performing	Proficient
Blood/Blood Product Infusion
Argon Beam Coagulator

Autoclave

Bair Hugger

Blood/Fluid Warmer

Camera/Video Systems

a. Camera controller

b. Light source

c. Printers

d. VCR's

CD Players

Computer Skills/Abilities

Cardiac Monitor

Cell Saver

Cryo Unit for Cardiac Surgery

Cry-ophthalmic Unit

Defibrillator

Dermatome

a. Padgett

b. Zimmer

Drills

a. 3-M maxi driver

b. Codman craniotome

c. Hall air driver

d. Hall dental

e. Hall neurotome

f. Midax Rex/Anspach

g. Minidriver

h. Stryker

i. Surgairtome

j. Synthes A-O Drill

EQUIPMENT & SUPPLIES


	Never Performed	Limited Experience	Comfortable Performing	Proficient
Emerson Thoracic Pump
ESU Cautery

Fiber Optic Luminator

Flash Autoclave

Fracture Tables

a. Chick/Marquet

b. Jackson

c. Skytron/Rush

Internal Stapling Devices

Kreiselman Resuscitator

Laser

a. CO2

b. Holmium

c. Yag

d. Other:

Mesh graft

Microscopes

Nitrous Oxide Bank

Continuous SVO2 & CO Monitor

Pleurevac Chest Drainage System

Pneumatic Tourniquet

Pulse Oximeter

Steris Unit

Suction Units

Teletherometer

Vac-Pac Positioner

Computer Charting Systems

Infusion Delivery Devices (specify)

PRIMARY OR EXPERIENCE

Endoscopy

Cardiothoracic

General Surgery

Gynecologic

Neurosurgical

Ophthalmologic

Oral

Orthopedic

Otorhinolaryngologic

Plastic

Transplant

Trauma

Urologic

Vascular

Do you speak any languages other than English?

Yes

If yes, which language(s)?

Age Specific Skills

Check the box under EACH age group that you have experience with and are comfortable with for each skill below.

Neonates(0-30 days)

Infants(1 mo-1 yr)

Toddlers(1-3 yrs)

Preschool(4-6 yrs)

School Age(7-12 yrs)

Adolescent(13-18 yrs)

Young Adult(19-39 yrs)

Middle Adults(40-64 yrs)

Older Adults(65+ yrs)

Understands the different communication needs for the age group & changes communication methods and terminology accordingly

Neonates(0-30 days)

Infants(1 mo-1 yr)

Toddlers(1-3 yrs)

Preschool(4-6 yrs)

School Age(7-12 yrs)

Adolescent(13-18 yrs)

Young Adult(19-39 yrs)

Middle Adults(40-64 yrs)

Older Adults(65+ yrs)

Understands the different medications, dosages and possible side effects for the age group and administers medications appropriately

Neonates(0-30 days)

Infants(1 mo-1 yr)

Toddlers(1-3 yrs)

Preschool(4-6 yrs)

School Age(7-12 yrs)

Adolescent(13-18 yrs)

Young Adult(19-39 yrs)

Middle Adults(40-64 yrs)

Older Adults(65+ yrs)

Understands the different safety risks for the age group and alters the environment accordingly

Neonates(0-30 days)

Infants(1 mo-1 yr)

Toddlers(1-3 yrs)

Preschool(4-6 yrs)

School Age(7-12 yrs)

Adolescent(13-18 yrs)

Young Adult(19-39 yrs)

Middle Adults(40-64 yrs)

Older Adults(65+ yrs)

Understands the normal growth and development for the age group and adapts care accordingly

Neonates(0-30 days)

Infants(1 mo-1 yr)

Toddlers(1-3 yrs)

Preschool(4-6 yrs)

School Age(7-12 yrs)

Adolescent(13-18 yrs)

Young Adult(19-39 yrs)

Middle Adults(40-64 yrs)

Older Adults(65+ yrs)

I hereby certify that ALL information I have provided to Clover Health Services, 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.