|
|
Operating Room
Surgical Technologist Skills Checklist
|
|
NAME
|
|
|
|
|
|
|
|
|
LAST 4 OF SSN
|
|
|
|
|
|
|
|
|
|
DATE
|
|
|
|
|
|
|
|
|
|
I hereby certify that
ALL information I have provided to IMCS Group 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.
|
|
|
|
|
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 Scale:
|
1 = No Experience
2 = Need Training
3 = Able to perform with supervision
4 = Able to perform independently
|
|
| |
|
|
|
|
Rating Stars (Click)
|
GENERAL SURGERY
|
1
|
2
|
3
|
4
|
|
|
|
Abdominal Perineal
Resection
|
|
|
|
|
|
|
|
Anal
Fistulectomy/Anoplasty
|
|
|
|
|
|
|
|
Appendectomy/Cholescystectomy
|
|
|
|
|
|
|
|
Breast Biopsy
|
|
|
|
|
|
|
|
Bronchoscopy
|
|
|
|
|
|
|
|
Colon Resection/Surgery
|
|
|
|
|
|
|
|
Colostomy
|
|
|
|
|
|
|
|
Esophagogastroduodenoscopy
w/ Biopsy
|
|
|
|
|
|
|
|
Esophagoscopy
|
|
|
|
|
|
|
|
Exploratory Laparotomy
|
|
|
|
|
|
|
|
Flexible Sigmoidoscopy
|
|
|
|
|
|
|
|
Fundoplication
|
|
|
|
|
|
|
|
Gastrectomy
|
|
|
|
|
|
|
|
Gastric Bypass/Roux-en-Y
|
|
|
|
|
|
|
|
Gastrostomy
|
|
|
|
|
|
|
|
Hemorrhoidectomy
|
|
|
|
|
|
|
|
Herniorrhaphy - Inguinal,
Ventral, Femoral, Umbilical
|
|
|
|
|
|
|
|
Insertion of Port-a-Cath,
Hickman, Broviac
|
|
|
|
|
|
|
|
Laparascopic General
Surgery Procedures
|
|
|
|
|
|
|
|
Laparoscopic General
Surgeries
|
|
|
|
|
|
|
|
Laparoscopic Nissen
Fundoplication
|
|
|
|
|
|
|
|
Liver Biopsy
|
|
|
|
|
|
|
|
Mastectomy
|
|
|
|
|
|
|
|
Percutaneous Endoscopic
Gastrostomy
|
|
|
|
|
|
|
|
Splenectomy
|
|
|
|
|
|
|
|
Thoracoscopy/Nuss
Procedure
|
|
|
|
|
|
|
|
Thyroidectomy
|
|
|
|
|
|
|
Rating Stars
(Click)
|
THORACIC
|
1
|
2
|
3
|
4
|
|
|
|
Endoscopic Thoracic
Procedures
|
|
|
|
|
|
|
|
Esophagogastrectomy
|
|
|
|
|
|
|
|
Mediastinotomy/Sternotomy
|
|
|
|
|
|
|
|
Thoracoscopy/Nuss
Procedure
|
|
|
|
|
|
|
|
Thoracotomy
|
|
|
|
|
|
|
Rating Stars
(Click)
|
ORTHOPEDIC
|
1
|
2
|
3
|
4
|
|
|
|
Total Joint Replacement
|
|
|
|
|
|
|
|
Closed Reduction of
Fracture
|
|
|
|
|
|
|
|
External Fixator
|
|
|
|
|
|
|
|
Cannulated Hip Screws
|
|
|
|
|
|
|
|
Bankhart Procedure
|
|
|
|
|
|
|
|
Birmingham Procedure
|
|
|
|
|
|
|
|
Carpal Tunnel Release
|
|
|
|
|
|
|
|
Arthroscopy
|
|
|
|
|
|
|
|
Anterior Cruciate Ligament
Reconstruction
|
|
|
|
|
|
|
Rating Stars
(Click)
|
NEUROLOGICAL
|
1
|
2
|
3
|
4
|
|
|
|
Craniotomy
|
|
|
|
|
|
|
|
Steriotactic Guided Brain
Biopsy
|
|
|
|
|
|
|
|
Laminectomy
|
|
|
|
|
|
|
|
Laparoscopic Anterior
Laminectomy
|
|
|
|
|
|
|
|
Insertion of Vagal Nerve
Stimulator
|
|
|
|
|
|
|
|
Insertion of VP Shunt
|
|
|
|
|
|
|
|
Spinal Fusion
|
|
|
|
|
|
|
|
Anterior Cervical
Discectomy with Fusion
|
|
|
|
|
|
|
|
Posterior Cervical
Laminectomy
|
|
|
|
|
|
|
Rating Stars
(Click)
|
GENITOURINARY
|
1
|
2
|
3
|
4
|
|
|
|
Vasicaurethropexy
|
|
|
|
|
|
|
|
Marshall Marchetti
|
|
|
|
|
|
|
|
Circumcision
|
|
|
|
|
|
|
|
Cystoscopy/Cystogram/Pyelogram
|
|
|
|
|
|
|
|
Prostatectomy
|
|
|
|
|
|
|
|
Nephrectomy
|
|
|
|
|
|
|
|
Orchidectomy/Orchidopexy
|
|
|
|
|
|
|
|
Ureterostomy
|
|
|
|
|
|
|
|
Laparoscopic Assisted GU
Procedures
|
|
|
|
|
|
|
|
Robotic Assisted GU
Procedures
|
|
|
|
|
|
|
|
Hydrocelectomy
|
|
|
|
|
|
|
|
Repair of Hypospadias
|
|
|
|
|
|
|
|
Retrograde Pyelogram
|
|
|
|
|
|
|
Rating Stars
(Click)
|
GYNECOLOGICAL
|
1
|
2
|
3
|
4
|
|
|
|
Abdominal Hysterectomy
|
|
|
|
|
|
|
|
Anterior Posterior Repair
|
|
|
|
|
|
|
|
C-Section
|
|
|
|
|
|
|
|
D & C
|
|
|
|
|
|
|
|
Laparoscopic Assisted
Hysterectomy
|
|
|
|
|
|
|
|
Laparotomy with
Microtuboplasty
|
|
|
|
|
|
|
|
Robotic Assisted GYN
Procedures
|
|
|
|
|
|
|
|
Vaginal Delivery
|
|
|
|
|
|
|
|
Vaginal Hysterectomy
|
|
|
|
|
|
|
Rating Stars
(Click)
|
EAR/NOSE/THROAT
|
1
|
2
|
3
|
4
|
|
|
|
Endoscopic ENT Procedures
|
|
|
|
|
|
|
|
Laryngectomy
|
|
|
|
|
|
|
|
Mastoidectomy
|
|
|
|
|
|
|
|
Myringotomy with Insertion
of Tubes
|
|
|
|
|
|
|
|
Radical Neck
|
|
|
|
|
|
|
|
Septoplasty
|
|
|
|
|
|
|
|
Tonsillectomy &
Adenoidectomy
|
|
|
|
|
|
|
|
Tracheostomy
|
|
|
|
|
|
|
|
Tympanoplasty
|
|
|
|
|
|
|
Rating Stars
(Click)
|
CRANIOFACIAL/ORAL/PLASTICS
|
1
|
2
|
3
|
4
|
|
|
|
Craniectomy
|
|
|
|
|
|
|
|
Craniofacial
Reconstruction
|
|
|
|
|
|
|
|
Dental Surgery
|
|
|
|
|
|
|
|
Leforte 1
Maxillary/Sagittal Osteotomy
|
|
|
|
|
|
|
|
ORIF Mandibular Fracture
|
|
|
|
|
|
|
|
Otoplasty
|
|
|
|
|
|
|
|
Reconstruction of Ear
|
|
|
|
|
|
|
|
Removal of Arch Bars
|
|
|
|
|
|
|
|
Repair of Cleft Lip, Nose,
Palate
|
|
|
|
|
|
|
|
Rhinoplasty
|
|
|
|
|
|
|
Rating Stars
(Click)
|
PLASTIC
|
1
|
2
|
3
|
4
|
|
|
|
Blephoroplasty
|
|
|
|
|
|
|
|
Breast Reconstruction with
Implant
|
|
|
|
|
|
|
|
Breast Reduction
Mammoplasty
|
|
|
|
|
|
|
|
Face Lift
|
|
|
|
|
|
|
|
Mastectomy with Tram Flap
Reconstruction
|
|
|
|
|
|
|
|
Split Thickness Skin Graft
|
|
|
|
|
|
|
|
Suction Lipectomy
|
|
|
|
|
|
|
Rating Stars
(Click)
|
TRANSPLANTS
|
1
|
2
|
3
|
4
|
|
|
|
Heart
|
|
|
|
|
|
|
|
Lung
|
|
|
|
|
|
|
|
Liver
|
|
|
|
|
|
|
|
Pancreas
|
|
|
|
|
|
|
|
Eye
|
|
|
|
|
|
|
|
Organ Donation
|
|
|
|
|
|
|
Rating Stars
(Click)
|
OPHTHAMOLOGY
|
1
|
2
|
3
|
4
|
|
|
|
Cataract Extraction with
Implant
|
|
|
|
|
|
|
|
Vitrectomy
|
|
|
|
|
|
|
|
Scleral Buckle
|
|
|
|
|
|
|
|
Cataract Aspiration;
Anterior Vitrectomy
|
|
|
|
|
|
|
|
Corneal Transplant
|
|
|
|
|
|
| |
If no PEDIATRICS
Experience, skip to EQUIPMENT section
|
|
|
Rating Stars
(Click)
|
CARDIOVASCULAR
|
1
|
2
|
3
|
4
|
|
|
|
Aorta Repair
|
|
|
|
|
|
|
|
Aorto-Bifemoral/Femoral-Pop
Bypass Graft
|
|
|
|
|
|
|
|
Arterial Switch
|
|
|
|
|
|
|
|
ASD/VSD Repair
|
|
|
|
|
|
|
|
Atrial Septectomy
|
|
|
|
|
|
|
|
Bidirectional Glenn
|
|
|
|
|
|
|
|
BT Shunt
|
|
|
|
|
|
|
|
Cardiac Bypass Surgery
|
|
|
|
|
|
|
|
Carotid Endarterectomy
|
|
|
|
|
|
|
|
ECMO
Insertion/Decannulation
|
|
|
|
|
|
|
|
Endoscopic Vascular
Procedures
|
|
|
|
|
|
|
|
Femoral Popliteal Bypass
Graft
|
|
|
|
|
|
|
|
Fontan Procedure
|
|
|
|
|
|
|
|
Laparascopic Cardiac
Surgery
|
|
|
|
|
|
|
|
Norwood Procedure
|
|
|
|
|
|
|
|
Pacemaker
|
|
|
|
|
|
|
|
PDA Ligation
|
|
|
|
|
|
|
|
Repair of Coarctation of
Aorta
|
|
|
|
|
|
|
|
Robotic Assisted Cardiac
Surgery
|
|
|
|
|
|
|
|
Ross Procedure
|
|
|
|
|
|
|
|
Tetralogy of Fallot Repair
|
|
|
|
|
|
|
|
Valve Repair/Replacement
|
|
|
|
|
|
|
|
Valve Replacement/Repair
|
|
|
|
|
|
|
|
Ventricular Assist Device
|
|
|
|
|
|
|
|
Ventricular Assist Device
|
|
|
|
|
|
|
Rating Stars
(Click)
|
TRANSPLANT
|
1
|
2
|
3
|
4
|
|
|
|
Heart
|
|
|
|
|
|
|
|
Kidney
|
|
|
|
|
|
|
|
Liver/Pancreas
|
|
|
|
|
|
|
|
Lung
|
|
|
|
|
|
|
|
Organ Donation
|
|
|
|
|
|
|
Rating Stars
(Click)
|
OPHTHAMOLOGY
|
1
|
2
|
3
|
4
|
|
|
|
Corneal Transplant
|
|
|
|
|
|
|
|
Dacrocystorhinostomy
|
|
|
|
|
|
|
|
Excision of Chalazion
|
|
|
|
|
|
|
|
Eye Muscle Surgery
|
|
|
|
|
|
|
|
Levator Resection
|
|
|
|
|
|
|
|
Orbitotomy of Eye
|
|
|
|
|
|
|
|
Repair of Ptosis
|
|
|
|
|
|
|
Rating Stars
(Click)
|
EAR/NOSE/THROAT
|
1
|
2
|
3
|
4
|
|
|
|
Cochlear Implant
|
|
|
|
|
|
|
|
Laryngotracheoplasty
|
|
|
|
|
|
|
|
Myringotomy with Tubes
|
|
|
|
|
|
|
|
Septoplasty
|
|
|
|
|
|
|
|
Suspension
Microlaryngoscopy
|
|
|
|
|
|
|
|
Tonsillectomy &
Adenoidectomy
|
|
|
|
|
|
|
|
Tracheostomy
|
|
|
|
|
|
|
|
Turbinate Reduction
|
|
|
|
|
|
|
|
Tympanoplasty/Typanomastoidectomy
|
|
|
|
|
|
|
Rating Stars
(Click)
|
CRANIOFACIAL/ORAL/PLASTICS
|
1
|
2
|
3
|
4
|
|
|
|
Craniectomy
|
|
|
|
|
|
|
|
Craniofacial
Reconstruction
|
|
|
|
|
|
|
|
Dental Surgery
|
|
|
|
|
|
|
|
Leforte 1
Maxillary/Sagittal Osteotomy
|
|
|
|
|
|
|
|
Mandibular Osteotomy
|
|
|
|
|
|
|
|
ORIF Mandibular Fracture
|
|
|
|
|
|
|
|
Otoplasty
|
|
|
|
|
|
|
|
Reconstruction of Ear
|
|
|
|
|
|
|
|
Repair of Cleft Lip, Nose,
Palate
|
|
|
|
|
|
|
|
Rhinoplasty
|
|
|
|
|
|
|
|
Skin Graft
|
|
|
|
|
|
|
Rating Stars
(Click)
|
ORTHOPEDICS
|
1
|
2
|
3
|
4
|
|
|
|
Acetabuloplasty/Triple
Innominate
|
|
|
|
|
|
|
|
Arthroscopy of Knee,
Wrist, Shoulder
|
|
|
|
|
|
|
|
Closed Reduction,
Percutaneous Pin
|
|
|
|
|
|
|
|
External Fixator
(Ilizarov/Orthofix)
|
|
|
|
|
|
|
|
ORIF Shoulder, Humerus,
Tibia, Femur
|
|
|
|
|
|
|
|
Osteotomy/VDRD/Calcaneal/Metatarsal
|
|
|
|
|
|
|
|
Spinal Fusion/Spinal with
Instrumentation
|
|
|
|
|
|
|
|
Tendoachilles Lengthening
|
|
|
|
|
|
|
Rating Stars
(Click)
|
OR EQUIPMENT
|
1
|
2
|
3
|
4
|
|
|
|
Electrocautery (ESU)
|
|
|
|
|
|
|
|
Laparoscopy Systems
|
|
|
|
|
|
|
|
Neuro
|
|
|
|
|
|
|
|
OR Fracture Tables (List
types below)
|
|
|
|
|
|
| |
List Types
|
|
|
|
|
Orthopedic Total Joint
Systems
|
|
|
|
|
|
|
|
Power Equipment
|
|
|
|
|
|
|
|
Robotics Systems (List
types below)
|
|
|
|
|
|
| |
List Types
|
|
|
|
|
Spinal Fusion
Instrumentation
|
|
|
|
|
|
|
Rating Stars
(Click)
|
PROFESSIONAL KNOWLEDGE AND
SKILLS
|
1
|
2
|
3
|
4
|
|
|
|
Malignant Hyperthermia
Protocol
|
|
|
|
|
|
|
|
Infection
Prevention
|
|
|
|
|
|
|
|
Isolation Precautions
|
|
|
|
|
|
|
|
National Patient Safety
Goals/Core Measures
|
|
|
|
|
|
|
|
Universal Protocol
|
|
|
|
|
|
|
Rating Stars
(Click)
|
EMR
|
1
|
2
|
3
|
4
|
|
|
|
Epic
|
|
|
|
|
|
|
|
Picis
|
|
|
|
|
|
|
|
Cerner
|
|
|
|
|
|
|
|
Eclipsys
|
|
|
|
|
|
|
|
McKesson
|
|
|
|
|
|
|
|
Meditech
|
|
|
|
|
|
|
|
Other Computerized System
|
|
|
|
|
|
|
|
Computerized Physician
Order Entry
|
|
|
|
|
|
| |
EMR Conversion
|
|
|
|
|
MY EXPERIENCE IS
PRIMARILY IN:
|
|
|
Unit
|
No. of Years
|
Unit
|
No. of Years
|
|
|
BURN
|
|
|
|
|
|
CRITICAL UNIT
|
|
|
|
|
|
PACU
|
|
|
|
|
|
NEUROLOGY
|
|
|
|
|
|
TELEMETRY
|
|
|
|
|
|
MEDICAL
|
|
|
|
|
|
SURGICAL
|
|
|
|
|
|
ONCOLOGY
|
|
|
|
|
|
ORTHOPEDICS
|
|
|
|
|
|
OPERATING
ROOM
|
|
|
|
|
|
EMERGENCY
ROOM
|
|
|
|
|
|
TRAUMA CENTER
LEVEL 1
|
|
|
|
|
|
COMMUNITY ER
|
|
|
|
|
|
RURAL ER
|
|
|
|
|
|
CERTIFICATIONS
|
|
|
Expiry Date :
|
|
|
|
BLS
|
|
|
|
|
Certified Surgical
Technologist (CST)
|
|
|
|
|
Certified Sterile
Processing Technologist (CSPT)
|
|
|
| |
Other: Specify
|
|
|
|
|
Rating Stars
(Click)
|
AGE APPROPRIATE CARE
|
1
|
2
|
3
|
4
|
|
|
|
Newborn/Neonatal (birth –
30 days)
|
|
|
|
|
|
|
|
Infant (30 days-1 year)
|
|
|
|
|
|
|
|
Toddler (1-3 years)
|
|
|
|
|
|
|
|
Preschool (3-5 years)
|
|
|
|
|
|
|
|
School Age Children (5-12
years)
|
|
|
|
|
|
|
|
Adolescent (12-17 years)
|
|
|
|
|
|
|
|
Young Adults (18-44 years)
|
|
|
|
|
|
|
|
Middle Adults (45-64
years)
|
|
|
|
|
|
|
|
Older Adults (>65
years)
|
|
|
|
|
|