OPERATING ROOM SKILLS CHECKLIST Name: Registered Nurse Technician CTS When completing this ckecklist, please indicate your level of proficiency in each area according to the scale below. Place a check mark in box which best describes your expertiese with each skill. CARDIOVASCULAR The scale is as follows: 1. Not performed 2. Intermitten experience 3. Very experienced. 1. Aortic Femoral Bypass graft 1 2 3 2. Femoral-Popliteal Bypass 1 2 3 3. Pacemaker Implantation 1 2 3 4. Care of patients with pacemaker 1 2 3 5. Cardiac cath lab A. Intra-Aortic Balloon Pump 1 2 3 6. Septal defects 1 2 3 7. Shunts 1 2 3 8. Coronary Artery Bypass Graft 1 2 3 9. Pediatric procedures 1 2 3 10.Valve replacement 1 2 3 11.Aortic aneurysm 1 2 3 ENT 1. Adenoidectomy/Tonsillectomy 1 2 3 2. Caldwell - Luc 1 2 3 3. Cleft lip/palate repair 1 2 3 4. Mastoidectomy 1 2 3 5. Middle ear procedure 1 2 3 6. Radical neck dissection 1 2 3 7. Rhinoplasty/septoplasty 1 2 3 8. Tracheotomy 1 2 3 EQUIPMENT 1. Camera/video systems 1 2 3
2. Cell saver 1 2 3 3. Cidex soak 1 2 3 4. Cryo-ophthalmic unit 1 2 3 5. CUSA 1 2 3 6. Vac-Pac/ Bean Bag 1 2 3 7. Hypo/Hyperthermia Unit 1 2 3 8. Drills and saws 1 2 3 9. Electrosurgical unit 1 2 3 10.Fiber optic luminator 1 2 3 11.Cavitron 1 2 3 12.Autoclave 1 2 3 13.Fracture tables 1 2 3 14.Stapling devices 1 2 3 15.Mesh graft/dermatome 1 2 3 16.Microscopes 1 2 3 17.Nitrogen tank 1 2 3 18.Pneumatic tourniquet 1 2 3 19.Steris unit 1 2 3 20.Pulsevac Irrigation 1 2 3 21.Autotransfusion Drain 1 2 3 22.Ligasure machine 1 2 3 GENERAL SURGERY 1. Abdominal peritoneal resection 1 2 3 2. Breast biopsy 1 2 3 3. Bowel resection 1 2 3 4. Gastric procedures 1 2 3 5. Hernia: open repair 1 2 3 6. Colostomy/Ileostomy 1 2 3 7. Appendectomy - open 1 2 3 8. Appendectomy - Laparoscopic 1 2 3 9. Cholecystectomy/Laparoscopic 1 2 3
10.Cholecystectomy/colongiogram-open 1 2 3 11.Hiatal herniorraphy 1 2 3 12.Hepatic resection 1 2 3 13.Hickman/Groshong/Portacath insertion 1 2 3 14.Rectal procedures 1 2 3 15.Pancreatectomy/pancreatogram 1 2 3 16.Splenectomy 1 2 3 17.Thyroidectomy 1 2 3 18.Colonoscopy/Sigmoidoscopy 1 2 3 19.Gastroscopy/ Esophagoscopy 1 2 3 20.Nissen fundoplication laparoscopic 1 2 3 GYNECOLOGY 1. Cesarean section 1 2 3 2. Dilation and Curettage (D&C) 1 2 3 3. TAH/BSO 1 2 3 4. Vaginal Hysterectomy 1 2 3 5. Marshall-Marchetti 1 2 3 6. Ovarian cystectomy 1 2 3 7. AP Repair 1 2 3 8. Laparoscopic procedures 1 2 3 9. Hysteroscopy 1 2 3 NEUROLOGY 1. Discectomy/laminectomy 1 2 3 2. Anterior/posterior cervical fusion 1 2 3 3. Cranioplasty/craniotomy tumor 1 2 3 4. Craniotomy for aneruysm 1 2 3 5. Shunt procedure/vp, VA/LP 1 2 3 6. Halo traction application 1 2 3 7. Pediatric procedures 1 2 3 8. Spinal fusion 1 2 3 9. Spinal fusion with instrumentation 1 2 3
OPTHALMOLOGY 1. Cataract extraction with IOL 1 2 3 2. Corneal transplants 1 2 3 3. Scleral buckle 1 2 3 4. Vitrectomy 1 2 3 5. Anterior procedures 1 2 3 6. Exterior procedures 1 2 3 7. Equipment: A. Legacy 1 2 3 B. Millenium 1 2 3 ORAL 1. Closed reduction facial fractures and wiring 1 2 3 2. Dental procedures 1 2 3 3. LeFort osteotomies 1 2 3 4. Mandibular osteotomy 1 2 3 5. TMJ procedures 1 2 3 ORTHOPEDICS 1. Amputation - leg, arm 1 2 3 2. Carpel tunnel release 1 2 3 3. Hand surgery 1 2 3 4. Hip compression nails, screws and pinning 1 2 3 5. Bipolar/unipolar hip prosthesis 1 2 3 6. Iliac crest bone graft 1 2 3 7. Intramedullary rods 1 2 3 8. Open reduction internal fixation 1 2 3 9. Patellectomy 1 2 3 10.Reimplantation of digits 1 2 3 11.Rotator cuff repair 1 2 3 12.Total joint knee/shoulder/wrist 1 2 3 13.Arthroscopic procedures 1 2 3 14.Pediatric procedures 1 2 3 PLASTICS
1. Free Flap/Rotational Flap 1 2 3 2. Radical Mastectomy 1 2 3 3. Mastectomy 1 2 3 4. Adominoplasty 1 2 3 5. Blepharoplasty 1 2 3 6. Face lift 1 2 3 7. Augmentation mammoplasty 1 2 3 8. Reduction mammoplasty 1 2 3 9. Reconstructive mammoplasty tram flaps 1 2 3 10.Skin graft 1 2 3 THORACIC 1. Thombectomy/Embolectomy 1 2 3 2. Lobectomy 1 2 3 3. Thoracotomy 1 2 3 4. Chest tube 1 2 3 5. Bronchoscopy 1 2 3 6. Mediastinoscopy 1 2 3 7. Thoracoscopy 1 2 3 TRANSPLANTS 1. Bone marrow 1 2 3 2. Heart/Lung 1 2 3 3. Kidney 1 2 3 4. Corneal 1 2 3 5. Harvesting 1 2 3 6. Liver 1 2 3 7. Pancreas 1 2 3 UROLOGY 1. Implants; penile, testicular 1 2 3 2. Lithotripsy 1 2 3 3. Nephrectomy 1 2 3 4. Orchiopexy 1 2 3
5. Prostatectomy 1 2 3 6. TURP 1 2 3 7. Vasovasostomy 1 2 3 8. Cystocopy/Ureteroscopy 1 2 3 PROFESSIONAL EXPERIENCE AND CERTIFICATIONS 1. Years of experience as: RN Tech. 2. Years of experience in: Adult Pediatric. 3. Area of most proficiency: 4. Area of least proficiency: 5. Are you willing to assist with elective abortions? Yes No 6. Are you Laser certified? Yes No The information I have given is true and accurate to the best of my knowledge. Please sign and date below. SIGNATURE: (Last 4 digits of your SSN) Reenter your last 4 digits of your SSN: DATE: eset