CYNET_SYSTEMS_MAIN_LOGO.gif   REGISTERED NURSE CVOR 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) SCRUB GENERAL SURGERY 1 2 3 4  
AKA/BKA (Amputation)  
Radical Mastectomy  
Abdominal - Perineal Resection  
Cholecystectomy (Open)  
Exploratory Laparatomy  
Appendectomy  
Rating Stars (Click) SCRUB CARDIAC 1 2 3 4  
DaVinci Procedures  
Coronary Artery By-Pass  
Mitral Valve Repair/Replacement  
Aortic Valve Replacement  
Multiple Valve Transposition  
Septal Defects  
Ventricular aneurysm Repair  
Bring Back Heart  
Pericardial Window  
Intra-Aortic Balloon Insertion  
Heartport or Similar CABG  
Thoraco approach Mid-Cab  
Aortic Arch Replacement  
Aortic Valve Conduit  
Mechanical Heart/LVAD  
Pediatric Hearts  
Tetrology of Fallot  
Chamberlain Procedure  
Femoral Artery Cannulation  
AICD Insertion  
Saphenous Vein Harvest  
Endoscopic Vein Harvest  
Gastric Artery Harvest  
Radial Vein Harvest  
Carotid Endarterectomy  
Abdominal Aortic Aneurysm  
Femoral-Popliteal By-Pass Graft  
Thrombectomy  
AV Shunt  
Pacemaker Insertion  
Rating Stars (Click) SCRUB LAPARASCOPIC PROCEDURES 1 2 3 4  
Cholecystectomy (Open)  
Appendectomy  
Hernia  
Nissan  
Colectomy  
Gastrectomy  
Inguinal/Ventral hernia Repair  
Splenectomy  
Bowel Rescetion/Colostomy  
Thyroidectomy  
Rectal Procedures  
Esophagascopy/Gastrocopy  
Rating Stars (Click) SCRUB PEDIATRIC CASES 1 2 3 4  
Inguinal Hernia Repair  
Pyloric Stenosis  
Circumcision  
Exploratory Laparotomy  
Rating Stars (Click) SCRUB VASCULAR SURGERY 1 2 3 4  
Carotid Endarterectomy  
Abdominal Aoric Aneurysm  
Femoral-Popliteal By-Pass Graft (Insitu)  
Femoral-Popliteal By-Pass Graft (Graph)  
Portacath, Tesio, Hickman  
AV Shunt  
Thrombecomy  
Pacemaker Insertion  
Arterial Stenting  
Intra-Operative Angioplasty  
Subclavian/Carotid By-Pass  
Rating Stars (Click) SCRUB ORTHOPEDICS 1 2 3 4  
Total Hip Replacement  
Bipolar Hip  
Compression Hip Screw  
Total Knee Replacement  
Knee Artoscopy  
ACL Knee Repair  
harrington Rod or Similar  
I.M. Rodding  
Hand and Foot procedures  
Mini Fragment Screws & Plates  
External Fixation  
Shoulder Repair  
Shoulder Arthoscopy  
Spinal Fusion  
Fracture Table Set-Up  
Drills, Saws and Reamers  
Rating Stars (Click) SCRUB GYNECOLOGY 1 2 3 4  
D&C  
Diagnostic Laparascope  
Laparoscopic Asst'd Vaginal Hysterectomy  
Abdominal Hysterectomy  
Vaginal Hysterectomy  
Anterior/Posterior Repair  
MMK (Marshall Marchetti Krantz)  
Tuboplasty  
BLT (Bilateral Tubal Ligation)  
C-Section  
Rating Stars (Click) SCRUB UROLOGY 1 2 3 4  
Radical Prostatectomy  
Radical Lymph Node Dissection  
Insertion Penile Prosthesis  
Hydrocelectomy  
Cystoscopy  
Ureteroscopy  
TURP/TURBT  
Rating Stars (Click) SCRUB NEUROLOGY 1 2 3 4  
Cervical Laminectomy (Anterior)  
Cervical Laminectomy (Posterior)  
Lumbar Lamincetomy, Discectomy  
Percutaneous Micro Discectomy  
Craniotomy for Tumor  
Craniotomy for Aneurysm  
Burr Holes  
VP Shunts  
Transphenoidal Hypothypectomy  
Harrington Rod or Similar  
SCRUB PLASTICS  
Mammoplasty  
Facelifts  
Skin Grafts  
Rhinoplasty  
Cleft Lip Repair  
Abdominalplasty  
Blepharoplasty  
Otoplasty  
Muscle Flaps  
Trauma  
Transplant Surgery  
Organ Procurements (Harvest)  
Rating Stars (Click) SCRUB ENT 1 2 3 4  
Middle Ear  
T&A  
Myringotomy  
Tympanoplasty  
Radical Neck Dissection  
Septoplasty  
Sinus Endoscopy  
Rating Stars (Click) SCRUB THORACIC 1 2 3 4  
Thoracotomy  
Thoracoscopy  
Rating Stars (Click) EMR 1 2 3 4  
Epic  
Cerner  
Eclipsys  
McKesson  
Meditech  
Other Computerized System  
Computerized Physician Order Entry  
Bar Coding for Medication Administration  
MY EXPERIENCE IS PRIMARILY IN:  
Unit No. of Years Unit No. of Years  
BURN POST PARTUM  
CRITICAL UNIT LABOR & DELIVERY  
PACU NEWBORN NURSERY  
NEUROLOGY LEVEL II NICU  
TELEMETRY LEVEL III NICU  
MEDICAL PICU  
SURGICAL  PEDIATRICS  
ONCOLOGY OB/GYN  
ORTHOPEDICS PSYCHIATRY  
OPERATING ROOM RRT  
EMERGENCY ROOM CRT  
TRAUMA CENTER LEVEL 1    
COMMUNITY ER    
RURAL ER    
Rating Stars (Click) Age Specific Competencies 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)