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Operating Room Skills Checklist
Please mark your level of experience
1. No theory and/or experience
2. Limited experience/need supervision and/or support
3. Experienced/minimal support needed to perform
4. Proficient/can perform independently
WORK SETTINGS
1
2
3
4
General OR
1
2
3
4
CVOR
1
2
3
4
Outpatient
1
2
3
4
Trauma
1
2
3
4
Peds-General OR
1
2
3
4
Peds-CVOR
1
2
3
4
First Assist
1
2
3
4
Scrub Experience
1
2
3
4
GENERAL SURGERY
1
2
3
4
Abdominal Perineal Resection
1
2
3
4
Appendectomy/Cholescystectomy
1
2
3
4
Breast Biopsy
1
2
3
4
Colon Resection/Surgery
1
2
3
4
Gastrectomy
1
2
3
4
Gastric Bypass/Roux-en-Y
1
2
3
4
Hemorrhoidectomy
1
2
3
4
Herniorrhaphy - Inguinal, Ventral, Femoral, Umbilical
1
2
3
4
Laparoscopic General Surgeries
1
2
3
4
Laparoscopic Nissen Fundoplication
1
2
3
4
Mastectomy
1
2
3
4
Splenectomy
1
2
3
4
Thyroidectomy
1
2
3
4
Scrub General Surgery
1
2
3
4
CARDIOVASCULAR
1
2
3
4
Aorta Repair
1
2
3
4
Aorto-Bifemoral/Femoral-Pop Bypass Graft
1
2
3
4
Cardiac Bypass Surgery
1
2
3
4
Carotid Endarterectomy
1
2
3
4
Endoscopic Vascular Procedures
1
2
3
4
Femoral Popliteal Bypass Graft
1
2
3
4
Laparascopic Cardiac Surgery
1
2
3
4
Robotic Assisted Cardiac Surgery
1
2
3
4
Valve Replacement/Repair
1
2
3
4
Ventricular Assist Device
1
2
3
4
Scrub CV Surgery
1
2
3
4
THORACIC
1
2
3
4
Endoscopic Thoracic Procedures
1
2
3
4
Esophagoogastrectomy
1
2
3
4
Mediastinotomy/Sternotomy
1
2
3
4
Thoracoscopy/Nuss Procedure
1
2
3
4
Thoracotomy
1
2
3
4
Scrub Thoracic Surgery
1
2
3
4
ORTHOPEDIC
1
2
3
4
Total Joint Replacement
1
2
3
4
Closed Reduction of Fracture
1
2
3
4
External Fixator
1
2
3
4
Cannulated Hip Screws
1
2
3
4
Bankhart Procedure
1
2
3
4
Birmingham Procedure
1
2
3
4
Carpal Tunnel Release
1
2
3
4
Arthroscopy
1
2
3
4
Anterior Cruciate Ligament Reconstruction
1
2
3
4
Open Reduction Internal Fixation
1
2
3
4
Scrub Orthopedics
1
2
3
4
NEUROLOGICAL
1
2
3
4
Craniotomy
1
2
3
4
Steriotactic Guided Brain Biopsy
1
2
3
4
Laminectomy
1
2
3
4
Laparoscopic Anterior Laminectomy
1
2
3
4
Insertion of Vagal Nerve Stimulator
1
2
3
4
Insertion of VP Shunt
1
2
3
4
Spinal Fusion
1
2
3
4
Anterior Cervical Discectomy with Fusion
1
2
3
4
Posterior Cervical Laminectomy
1
2
3
4
Scrub Neurological Surgery
1
2
3
4
GENITOURINARY
1
2
3
4
Vasicaurethropexy
1
2
3
4
Marshall Marchetti
1
2
3
4
Circumcision
1
2
3
4
Cystoscopy/Cystogram/Pyelogram
1
2
3
4
Prostatectomy
1
2
3
4
Nephrectomy
1
2
3
4
Orchidectomy/Orchidopexy
1
2
3
4
Ureterostomy
1
2
3
4
Laparoscopic Assisted GU Procedures
1
2
3
4
Robotic Assisted GU Procedures
1
2
3
4
Scrub GU Surgery
1
2
3
4
GYNECOLOGICAL
1
2
3
4
Abdominal Hysterectomy
1
2
3
4
Anterior Posterior Repair
1
2
3
4
C-Section
1
2
3
4
D & C
1
2
3
4
Laparoscopic Assisted Hysterectomy
1
2
3
4
Laparotomy with Microtuboplasty
1
2
3
4
Robotic Assisted GYN Procedures
1
2
3
4
Vaginal Delivery
1
2
3
4
Vaginal Hysterectomy
1
2
3
4
Scrub Gyn Surgery
1
2
3
4
EAR/NOSE/THROAT
1
2
3
4
Endoscopic ENT Procedures
1
2
3
4
Laryngectomy
1
2
3
4
Mastoidectomy
1
2
3
4
Myringotomy with Insertion of Tubes
1
2
3
4
Radical Neck
1
2
3
4
Septoplasty
1
2
3
4
Tonsillectomy & Adenoidectomy
1
2
3
4
Tracheostomy
1
2
3
4
Tympanoplasty
1
2
3
4
Scrub ENT Surgery
1
2
3
4
CRANIOFACIAL/ORAL
1
2
3
4
Craniectomy
1
2
3
4
Craniofacial Reconstruction
1
2
3
4
Dental Surgery
1
2
3
4
Leforte 1 Maxillary/Sagittal Osteotomy
1
2
3
4
ORIF Mandibular Fracture
1
2
3
4
Otoplasty
1
2
3
4
Reconstruction of Ear
1
2
3
4
Removal of Arch Bars
1
2
3
4
Repair of Cleft Lip, Nose, Palate
1
2
3
4
Rhinoplasty
1
2
3
4
Scrub Craniofacial/Oral
1
2
3
4
PLASTIC
1
2
3
4
Blephoroplasty
1
2
3
4
Breast Reconstruction with Implant
1
2
3
4
Breast Reduction Mammoplasty
1
2
3
4
Face Lift
1
2
3
4
Mastectomy with Tram Flap Reconstruction
1
2
3
4
Split Thickness Skin Graft
1
2
3
4
Suction Lipectomy
1
2
3
4
Scrub Plastics
1
2
3
4
TRANSPLANTS
1
2
3
4
Heart
1
2
3
4
Lung
1
2
3
4
Liver
1
2
3
4
Pancreas
1
2
3
4
Eye
1
2
3
4
Organ Donation
1
2
3
4
Scrub Transplants
1
2
3
4
OPHTHALMOLOGY
1
2
3
4
Cataract Extraction with Implant
1
2
3
4
Vitrectomy
1
2
3
4
Scleral Buckle
1
2
3
4
Cataract Aspiration; Anterior Vitrectomy
1
2
3
4
Corneal Transplant
1
2
3
4
Scrub Ophthalmology
1
2
3
4
If no PEDIATRICS Experience, skip to OR EQUIPMENT section
PEDIATRIC GENERAL SURGERY
1
2
3
4
Anal Fistulectomy/Anoplasty
1
2
3
4
Appendectomy/Cholecystectomy
1
2
3
4
Biopsy (Mass, Muscle, Lymph Node)
1
2
3
4
Bronchoscopy
1
2
3
4
Colostomy
1
2
3
4
Esophagogastroduodenoscopy w/ Biopsy
1
2
3
4
Esophagoscopy
1
2
3
4
Exploratory Laparotomy
1
2
3
4
Flexible Sigmoidoscopy
1
2
3
4
Fundoplication
1
2
3
4
Gastrostomy
1
2
3
4
Herniorrhaphy
1
2
3
4
Insertion of Port-a-Cath, Hickman, Broviac
1
2
3
4
Laparascopic General Surgery Procedures
1
2
3
4
Liver Biopsy
1
2
3
4
Percutaneous Endoscopic Gastrostomy
1
2
3
4
Thoracoscopy/Nuss Procedure
1
2
3
4
Scrub Peds General Surgery
1
2
3
4
PEDIATRIC GENITOURINARY
1
2
3
4
Circumcision
1
2
3
4
Cystoscopy/Cystogram/Pyelogram
1
2
3
4
Hydrocelectomy
1
2
3
4
Nephrectomy
1
2
3
4
Orchidectomy/Orchidopexy
1
2
3
4
Repair of Hypospadias
1
2
3
4
Retrograde Pyelogram
1
2
3
4
Ureterostomy
1
2
3
4
Scrub Peds GU
1
2
3
4
PEDIATRIC NEURO
1
2
3
4
Craniotomy
1
2
3
4
Insertion of Vagal Nerve Stimulator
1
2
3
4
Insertion of VP Shunt
1
2
3
4
Laminectomy
1
2
3
4
Scrub Peds Neuro
1
2
3
4
PEDIATRIC CARDIAC/VASCULAR
1
2
3
4
Arterial Switch
1
2
3
4
ASD/VSD Repair
1
2
3
4
Atrial Septectomy
1
2
3
4
Bidirectional Glenn
1
2
3
4
BT Shunt
1
2
3
4
ECMO Insertion/Decannulation (Cardiac)
1
2
3
4
Fontan Procedure
1
2
3
4
Norwood Procedure
1
2
3
4
Pacemaker
1
2
3
4
PDA Ligation
1
2
3
4
Repair of Coarctation of Aorta
1
2
3
4
Ross Procedure
1
2
3
4
Tetralogy of Fallot Repair
1
2
3
4
Valve Repair/Replacement
1
2
3
4
Ventricular Assist Device
1
2
3
4
Scrub Peds Cardiac/Vascular
1
2
3
4
PEDIATRIC TRANSPLANT
1
2
3
4
Heart
1
2
3
4
Kidney
1
2
3
4
Liver/Pancreas
1
2
3
4
Lung
1
2
3
4
Organ Donation
1
2
3
4
Scrub Peds Transplant
1
2
3
4
PEDIATRIC OPHTHALMOLOGY
1
2
3
4
Corneal Transplant
1
2
3
4
Dacrocystorhinostomy
1
2
3
4
Excision of Chalazion
1
2
3
4
Eye Muscle Surgery
1
2
3
4
Levator Resection
1
2
3
4
Orbitotomy of Eye
1
2
3
4
Repair of Ptosis
1
2
3
4
Scrub Peds Opthalmology
1
2
3
4
PEDIATRIC EAR/NOSE/THROAT
1
2
3
4
Cochlear Implant
1
2
3
4
Laryngotracheoplasty
1
2
3
4
Myringotomy with Tubes
1
2
3
4
Septoplasty
1
2
3
4
Suspension Microlaryngoscopy
1
2
3
4
Tonsillectomy & Adenoidectomy
1
2
3
4
Tracheostomy
1
2
3
4
Turbinate Reduction
1
2
3
4
Tympanoplasty/Typanomastoidectomy
1
2
3
4
Scrub Peds ENT
1
2
3
4
PEDIATRIC CRANIOFACIAL/ORAL/PLASTICS
1
2
3
4
Craniectomy
1
2
3
4
Craniofacial Reconstruction
1
2
3
4
Dental Surgery
1
2
3
4
Leforte 1 Maxillary/Sagittal Osteotomy
1
2
3
4
Mandibular Osteotomy
1
2
3
4
ORIF Mandibular Fracture
1
2
3
4
Otoplasty
1
2
3
4
Reconstruction of Ear
1
2
3
4
Repair of Cleft Lip, Nose, Palate
1
2
3
4
Rhinoplasty
1
2
3
4
Skin Graft
1
2
3
4
Scrub Peds C-Fl/Oral/Plastics
1
2
3
4
PEDIATRIC ORTHOPEDICS
1
2
3
4
Acetabuloplasty/Triple Innominate
1
2
3
4
Arthroscopy of Knee, Wrist, Shoulder
1
2
3
4
Closed Reduction, Percutaneous Pin
1
2
3
4
External Fixator (Ilizarov/Orthofix)
1
2
3
4
ORIF Shoulder, Humerus, Tibia, Femur
1
2
3
4
Osteotomy/VDRD/Calcaneal/Metatarsal
1
2
3
4
Spinal Fusion/Spinal with Instrumentation
1
2
3
4
Tendoachilles Lengthening
1
2
3
4
Scrub Peds Ortho
1
2
3
4
OR EQUIPMENT
1
2
3
4
Electrocautery (ESU)
1
2
3
4
Laparoscopy Systems
1
2
3
4
Neuro
1
2
3
4
OR Fracture Tables
1
2
3
4
Orthopedic Total Joint Systems
1
2
3
4
Power Equipment
1
2
3
4
Robotics Systems
1
2
3
4
Spinal Fusion Instrumentation
1
2
3
4
PROFESSIONAL KNOWLEDGE AND SKILLS
1
2
3
4
Malignant Hyperthermia Protocol
1
2
3
4
Administer and Monitor Moderate Sedation
1
2
3
4
Universal Protocol for Wrong Site Surgery
1
2
3
4
National Patient Safety Goals/Core Measures
1
2
3
4
Fall Risk Assessment/Prevention
1
2
3
4
Pressure Ulcer Risk Assessment/Prevention
1
2
3
4
Restraints/Use of Least Restrictive Device
1
2
3
4
Age Specific/Population-Based Care
1
2
3
4
Isolation Precautions
1
2
3
4
Infection Prevention
1
2
3
4
COMPUTERIZED CHARTING
1
2
3
4
Epic
1
2
3
4
Cerner
1
2
3
4
Eclipsys
1
2
3
4
McKesson
1
2
3
4
Meditech
1
2
3
4
Other Computerized System
1
2
3
4
Computerized Physician Order Entry
1
2
3
4
Bar Coding for Medication Administration
1
2
3
4
Yes
No
EMR Conversion
Yes
No
First Name
*
Last Name
*
Phone Number
*
Last 4 of Social Security Number
*
Email Address
*
Date Completed:
*
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By checking the "Agree" box and clicking “Submit” below you certify and acknowledge the information provided on this checklist is accurate to the best of your knowledge and an accurate representation of your abilities.
*
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