INSTRUCTIONS. #2 = Competent and familiar with procedure: I can perform this procedure with excellence, usually without assistance.
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1 PERIOPERATIVE SKILLS CHECKLIST Date: Full Name: INSTRUCTIONS Please provide accurate answers so we can correctly match your abilities to our client job requirements. Please check the level of experience and expertise you have in each skill category, using the following scale: #1 = Familiar with procedure but will usually or almost always require some assistance. #2 = Competent and familiar with procedure: I can perform this procedure with excellence, usually without assistance. #3 = Very competent: I have at least 12 months experience and can perform this procedure with excellence and without assistance. NOTE: Leave blank any procedures which you have no experience, training or low competence. SKILLS: Ear, Nose & Throat Adenoidectomy Caldwell Luc Cleft lip/palate repair Closed reduction nasal Ethmoidectomy Excision of salivary gland tumor Fenestration procedure Frontal flap sinus procedure Glossectomy Laryngectomy Mandibulectomy Mastoidectomy Maxillary advancement w/ hip graft Maxillectomy Myringoplasty Myringotomy w/ PE tube insertion Nasal polypectomy Open reduction facial Open reduction nasal Parotidectomy Pharyngeal flap procedure Radical neck dissection Ranulectomy Rhinoplasty/ septoplasty 1 Scrub SKILLS: 1 Scrub Selective osteotomy of maxilla/ mandible Sinus endoscopy Sinusotmy Stapedectomy Submucous resection Tonsillectomy Tracheostomy Tympanoplasty Endoscopic Procedures Bronchoscopy Colonoscopy Culdoscopy Cystoscopy Esophagoscopy Gastroscopy Hysteroscopy Laparoscopic procedures: Appendectomy Cholecystecomy/choloangi ogram Colon resection Hernia repair Nissen fundoplication Salpingo oophorectomy Tubal ligation Vaginal hysterectomy Laryngoscopy & microlaryngoscopy: Mediastinoscopy Pelviscopy Sigmoidoscopy Thorascopy
2 Scrub General Surgery Abdominal perineal resection Adrenalectomy Anal fissurectomy Appendectomy Breast biopsy Colectomy Colostomy/ ileostomy Gastrectomy Gastroplasty Hemorrhoidectomy Hepatic resection Herniorrhapy femoral, inguinal, umbilical Hiatal herniorrhaphy transabdominal/ transthoracic Hickman/Groshong/Portac h insertion Hydrocelectomy Imperforate anus reconstruction Lumbar sympahtectomy Ornpahlocele repair Pancreatectomy/ pancreatogram Pilonidal cystectomy Portal caval shunt Pyloric stenosis Radical mastectomy Splenectomy Tenchkhoff catheter placement Thyroglossal duct cyst excision Thyroidectomy Tracheostomy Vagotomy Gynecology Cesarean section Colpotomy Dialtion & curettage (D & C) Hysterectomy, abdominal Hysterectomy, vaginal Marshall Marchetti Marupialization, Bartholin Cyst Ovarian cystectomy Radium insertion Sacral spinus fixation Shirodkar procedure 2 Scrub Suction curettage Vaginal reconstruction Vaginectomy/vulvectomy Neurology A V malformation Anterior cervical fusion Anterior laparoscopic spine procedures Anterior lumbar interbody fusion (ALIF) Burr holes for subdural hematoma Carotid ligation Cervical sympathectomy Craniectomy for decompression Cranioplasty/craniotomy: Clipping of aneurysm Tumor excision Using stealth equipment (stealth craniotomy) Discectomy Hypophysectomy Insertion nerve stimulators/ medication pumps Laminectomy Myelomeningocele repair Pedicle screw insertion Posterior lumbar interbody fusion (PLIF) Shunt procedure/ VP,VA/ LP Spine fusion list systems you have used Ulnar nerve transfer Ventriculography procedure/ ventriculoscopy Ventriculostomy Opthalmology Cataract extraction with IOL Corneal transplant Dacryocystectomy Dacryocystorhinostomy Iridectomy Lid & muscle procedures Orbital implant Phaco emulsification Pterygium repair Recession resection Repair orbital blowout Sceleral buckle Vitrectomy
3 3 Scrub Oral Closed reduction facial s/wiring Excision odontoma Extraction of deciduous teeth Extraction of impacted molars Fractured jaws, mandibular and zagomatic LeFort osteotomies Maxillary procedure with graft Pediatric dentistry Sagittal osteotomy Temporomandibular joint (TMJ) with arthroplasty TMJ exploration Orthopedic Acetabular/pelvic ORIF Achilles tendon repair Amputation leg, arm Anterior cruciate ligament repair Application of external fixators: Extremities Pelvis Application of halo traction Arthroscopy: Ankle Elbow Knee Shoulder Arthroscopy Bipolar/unipolar hips Bunionectomy Calcaneal reconstruction Capsulorrhaphy Carpal tunnel release Closed reduction Hand surgery with implants Harrington rod instrumentation & / or Dwyer procedure Heel cord lengthening Hip compression nails & lag screws: Jewett Kuntscher rod Lottes Rush Schneider Zimmer Others (please list below:) Scrub Laminectomy Olecranon bursa, excision of Open reduction of, internal fixation with compression set Patellectomy Putt Platt/Bankart procedure/rotator cuff repair Reduction w/compression sets Reimplantation of digits Repair hammer toes Sacro ilia (SI) joint screws Sharrad procedure Spica cast, application of Spinal fusion Tendon transplants (hand & foot) Total joint replacement/revisions: Total hip Total knee Total shoulder Plastics Abdominal lipectomy Blepharoplasty Face lift Mammoplasty: Augmentation Reduction Tramflaps w/ reconstructive mammoplasty Mentoplasty Otoplasty Pedicle grafts Scar revisions Split thickness skin grafting Tissue expanders Thoracic & Open Heart Cervical rib excision Chamberlain procedure Closed thoractomy Correction pectus excavatum Esophagectomy Heller procedure Mitral commissurotomy Open heart procedures: Mitral or aortic valve replacement Patent ductus arteriosus Septal defect repairs Tetrology of Fallot
4 4 Scrub Pacemaker implantation endocardial Pericardiectomy Resection coarctation aorta Rib resection Thoracoplasty Tracheal resection Transthoracic diaphragmatic herniorrhapahy Transplant Bone Bone marrow Corneal Harvesting Heart Kidney Liver Lung Multi organ Pancreas Skin Trauma Burns Gunshot/stab wounds: Abdomen Chest Head Motor vehicle accidents (multiple injuries) Traumatic amputations Urology Adult circumcision Cystectomy Scrub Cystoscopy/ureteroscopy Hypospadias repair Implants; penile, testicular Lithotripsy Nephrectomy Nephrolithotomy Orchiopexy Prostatectomy: Perineal Supra pubic Pyeloplasty Radical node dissection Scott incontinence device TURP Ureterolithotomy Vasectomy Vasovasostomy Waterhouse procedure Vascular A V access graft Aortic aneurysm w/graft replacement Endarterectomy/carotid femoral Peripheral vascular bypass procedures Resection carotid aneurysm w/graft Thrombectomy /embolectomy Vena cava filter/umbrella Vena cava litigation Anesthesia Assist w/ intubation Conscious sedation administration & monitoring Management of malignant hyperthermia crisis Equipment Argon beam coagulator Bair Hugger Blood /fluid warmer Camera /video system: Camera controller Light source Printers VCRs Cardiac monitor & pacemaker Cell saver Cidex soak Cry ophthalmic unit Debrillator /pacer
5 5 Dermatome: Brown Padgett Zimmer Disposable grounding pads Drills: 3 M Maxi driver Codman craniotome Hall air driver Hall dental Hall neurotone Midax Rex /Anspach Minidriver Stryker drills (1) Large battery Stryker (2) Small bettery Stryker Surgairtone Synthes A 0 Drill Electrosurgical unit Emerson thorac pump Ethylene oxide sterilizer AMSCO Emerson thoracic pump Eye Magnet Fiber optic luminator list types Flash autoclave AMSCO Fracture tables: Chick table/ Marquet table Jackson table Rush table/skytron table Hypo/ hyperthermia unit Intestinal stapling devices: EEA GIA LDS TA Kreiselman resuscitator Laser: CO 2 Eye Yag Other (please list) Mesh graft Microscopes, list type Nerve stimulator Nitrous oxide bank Ohio suction units Orthopedic arm board w/drain Pleurevac disposable chest drainage Pneumatic tourniquet Sterad machine Steri vac aeration cabinet, 3 M, portable Steris unit Suction unit, disposable Tele thermometer Ultrasonic cleaner AMSCO Vac pac positioner Vacuum curettage Washer sanitizer AMSCO Washer sterilizer AMSCO Phlebotomy/ IV Therapy Equipment & procedures Administration of blood/blood products: Packed red blood cell Whole blood Assist w/ IA/ IV therapy: Insertion of A lines Insertion of CVP jugular / subclavian Insertion of Swan Ganz Drawing blood from central line Drawing venous blood Starting IVs: Angiocath Age Specific Practice Criteria Newborn/Neonate (birth 30 days) Infant (30 days 1 yr) Toddler (1 3 yrs) Preschooler (3 5 yrs) School age children (5 12 yrs) Adolescents (12 18 yrs) Young Adults (18 39 yrs) Middle Adults (39 64 yrs) Older Adults (64+ yrs) Care of patient with: Able to adapt care to incorporate normal growth and development. Able to adapt method and terminology of patient instructions to their age, comprehension and maturity level. Can ensure a safe environment reflecting specific needs of various groups. My experience is primarily in: Trauma referral center (Level I ER) Community ER (Level II ER) Rural ER
6 6 Certification: Please check the boxes below and indicate the expiration date for each certificate that you hold. If you do not know the exact date, please use the last date of the specific month (e.g., 05/31/2003). Certification Computerized charting system Medication administration ACLS BCLS CEN CCRN TNCC Other: Expiration Date I hereby certify all statements and claims as true and that any misrepresentation of the facts on this skills checklist is sufficient cause for dismissal at any time without prior notice even if I have been already employed. Full Name (Print): Signature: Retyped name acts as signature, if submitting form by Reviewed by : Date:
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