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Surgical Technologist Skills Checklist
WORKSETTING - My experience is in the following setting:
Yrs
General OR
Yrs
CVOR
Yrs
Outpatient
Yrs
Trauma
Yrs
Peds-General OR
Yrs
Peds-CVOR
Yrs
First Assist
Yrs
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
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
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
THORACIC
1
2
3
4
Endoscopic Thoracic Procedures
1
2
3
4
Esophagogastrectomy
1
2
3
4
Mediastinotomy/Sternotomy
1
2
3
4
Thoracoscopy/Nuss Procedure
1
2
3
4
Thoracotomy
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
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
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
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
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
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
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
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
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
OPHTHAMOLOGY
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
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
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
PEDIATRIC NERUO
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
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
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
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
PEDIATRIC OPHTHAMOLOGY
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
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
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
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
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
Infection Prevention
1
2
3
4
Isolation Precautions
1
2
3
4
National Patient Safety Goals/Core Measures
1
2
3
4
Universal Protocol
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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