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REGISTERED NURSE
OPERATING ROOM
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NAME
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LAST 4 OF SSN
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DATE
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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.
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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.
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Proficiency Scale:
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1 = No Experience
2 = Need Training
3 = Able to perform with supervision
4 = Able to perform independently
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Rating Stars (Click)
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WORKSETTING
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1
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2
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3
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4
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General OR
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CVOR
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Outpatient
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Trauma
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Peds-General OR
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Peds-CVOR
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First Assist
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Scrub Experience
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Rating Stars
(Click)
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GENERAL SURGERY
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1
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2
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3
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4
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Hemorrhoidectomy
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Abdominal Perineal
Resection
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Anal
Fistulectomy/Anoplasty
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Appendectomy/Cholescystectomy
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Breast Biopsy
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Bronchoscopy
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Colon Resection/Surgery
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Colostomy
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Esophagogastroduodenoscopy
w/ Biopsy
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Esophagoscopy
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Exploratory Laparotomy
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Flexible Sigmoidoscopy
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Fundoplication
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Gastrectomy
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Gastric Bypass/Roux-en-Y
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Gastrostomy
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Herniorrhaphy
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Herniorrhaphy - Inguinal,
Ventral, Femoral, Umbilical
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Insertion of Port-a-Cath,
Hickman, Broviac
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Laparoscopic General
Surgeries
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Laparoscopic Nissen
Fundoplication
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Liver Biopsy
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Mastectomy
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Percutaneous Endoscopic
Gastrostomy
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Scrub Peds General Surgery
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Splenectomy
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Thoracoscopy/Nuss
Procedure
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Thyroidectomy
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Rating Stars
(Click)
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CARDIOVASCULAR
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1
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2
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3
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4
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Aorta Repair
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Aorto-Bifemoral/Femoral-Pop
Bypass Graft
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Arterial Switch
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ASD/VSD Repair
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Atrial Septectomy
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Bidirectional Glenn
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BT Shunt
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Cardiac Bypass Surgery
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Carotid Endarterectomy
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ECMO
Insertion/Decannulation (Cardiac)
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Endoscopic Vascular
Procedures
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Femoral Popliteal Bypass
Graft
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Fontan Procedure
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Laparascopic Cardiac
Surgery
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Norwood Procedure
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Pacemaker
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PDA Ligation
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Repair of Coarctation of
Aorta
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Robotic Assisted Cardiac
Surgery
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Ross Procedure
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Scrub CV Surgery
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Tetralogy of Fallot Repair
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Valve Replacement/Repair
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Ventricular Assist Device
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Rating Stars
(Click)
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THORACIC
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1
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2
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3
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4
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Endoscopic Thoracic
Procedures
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Esophagoogastrectomy
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Mediastinotomy/Sternotomy
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Thoracoscopy/Nuss Procedure
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Thoracotomy
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Scrub Thoracic Surgery
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Rating Stars
(Click)
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ORTHOPEDIC
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1
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2
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3
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4
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Acetabuloplasty/Triple
Innominate
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Anterior Cruciate Ligament
Reconstruction
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Arthroscopy
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Arthroscopy of Knee,
Wrist, Shoulder
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Bankhart Procedure
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Birmingham Procedure
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Cannulated Hip Screws
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Carpal Tunnel Release
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Closed Reduction of
Fracture
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Closed Reduction,
Percutaneous Pin
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External Fixator
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Open Reduction Internal
Fixation
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ORIF Shoulder, Humerus,
Tibia, Femur
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Osteotomy/VDRD/Calcaneal/Metatarsal
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Scrub Orthopedics
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Scrub Peds Ortho
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Spinal Fusion/Spinal with
Instrumentation
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Tendoachilles Lengthening
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Total Joint Replacement
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Rating Stars
(Click)
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NEUROLOGICAL
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1
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2
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3
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4
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Anterior Cervical
Discectomy with Fusion
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Craniotomy
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Insertion of Vagal Nerve
Stimulator
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Insertion of VP Shunt
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Laminectomy
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Laminectomy
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Laparoscopic Anterior
Laminectomy
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Posterior Cervical
Laminectomy
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Scrub Neurological Surgery
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Scrub Peds Neuro
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Spinal Fusion
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Steriotactic Guided Brain
Biopsy
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Rating Stars
(Click)
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GENITOURINARY
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1
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2
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3
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4
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Vasicaurethropexy
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Marshall Marchetti
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Circumcision
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Cystoscopy/Cystogram/Pyelogram
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Prostatectomy
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Nephrectomy
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Orchidectomy/Orchidopexy
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Ureterostomy
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Laparoscopic Assisted GU
Procedures
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Robotic Assisted GU
Procedures
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Scrub GU Surgery
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Hydrocelectomy
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Repair of Hypospadias
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Retrograde Pyelogram
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Ureterostomy
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Scrub Peds GU
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Rating Stars
(Click)
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GYNECOLOGICAL
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1
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2
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3
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4
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Abdominal Hysterectomy
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Anterior Posterior Repair
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C-Section
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D & C
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Laparoscopic Assisted
Hysterectomy
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Laparotomy with
Microtuboplasty
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Robotic Assisted GYN
Procedures
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Vaginal Delivery
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Vaginal Hysterectomy
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Scrub Gyn Surgery
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Rating Stars
(Click)
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EAR/NOSE/THROAT
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1
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2
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3
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4
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Cochlear Implant
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Endoscopic ENT Procedures
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Laryngectomy
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Laryngotracheoplasty
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Mastoidectomy
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Myringotomy with Insertion
of Tubes
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Radical Neck
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Scrub ENT Surgery
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Septoplasty
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Suspension
Microlaryngoscopy
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Tonsillectomy &
Adenoidectomy
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Tracheostomy
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Turbinate Reduction
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Tympanoplasty/Typanomastoidectomy
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Rating Stars
(Click)
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OPHTHALMOLOGY
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1
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2
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3
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4
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Cataract Aspiration;
Anterior Vitrectomy
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Cataract Extraction with
Implant
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Corneal Transplant
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Dacrocystorhinostomy
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Excision of Chalazion
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Eye Muscle Surgery
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Levator Resection
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Orbitotomy of Eye
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PEDIATRICS
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Repair of Ptosis
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Scleral Buckle
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Scrub Ophthalmology
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Scrub Peds Opthalmology
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Vitrectomy
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Rating Stars
(Click)
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TRANSPLANT
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1
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2
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3
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4
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Heart
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Kidney
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Liver/Pancreas
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Lung
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Organ Donation
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Scrub Peds Transplant
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Rating Stars
(Click)
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CRANIOFACIAL/ORAL/PLASTICS
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1
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2
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3
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4
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Blephoroplasty
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Breast Reconstruction with
Implant
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Breast Reduction
Mammoplasty
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Craniectomy
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Craniofacial Reconstruction
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Dental Surgery
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Face Lift
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Leforte 1
Maxillary/Sagittal Osteotomy
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Mandibular Osteotomy
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Mastectomy with Tram Flap
Reconstruction
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ORIF Mandibular Fracture
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Otoplasty
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Reconstruction of Ear
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Repair of Cleft Lip, Nose,
Palate
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Rhinoplasty
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Scrub Craniofacial/Oral
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Scrub Peds
C-Fl/Oral/Plastics
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Skin Graft
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Split Thickness Skin Graft
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Suction Lipectomy
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Rating Stars
(Click)
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OR EQUIPMENT
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1
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2
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3
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4
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Electrocautery (ESU)
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Laparoscopy Systems
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Neuro
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OR Fracture Tables (List
Types)
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Orthopedic Total Joint
Systems
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Power Equipment
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Robotics Systems (List
types)
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Spinal Fusion
Instrumentation
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Rating Stars
(Click)
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PROFESSIONAL KNOWLEDGE AND
SKILLS
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1
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2
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3
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4
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Malignant Hyperthermia
Protocol
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Administer and Monitor
Moderate Sedation
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Universal Protocol for
Wrong Site Surgery
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National Patient Safety
Goals/Core Measures
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Fall Risk
Assessment/Prevention
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Pressure Ulcer Risk
Assessment/Prevention
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Restraints/Use of Least
Restrictive Device
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Age
Specific/Population-Based Care
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Isolation Precautions
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Infection Prevention
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Rating Stars
(Click)
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EMR
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1
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2
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3
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4
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Epic
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Cerner
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Eclipsys
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McKesson
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Meditech
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Other Computerized System
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Computerized Physician
Order Entry
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EMR Conversion
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Yes/No
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MY EXPERIENCE IS
PRIMARILY IN:
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Unit
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No. of Years
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Unit
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No. of Years
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BURN
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POST PARTUM
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CRITICAL UNIT
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LABOR & DELIVERY
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PACU
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NEWBORN NURSERY
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NEUROLOGY
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LEVEL II NICU
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TELEMETRY
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LEVEL III NICU
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MEDICAL
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PICU
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SURGICAL
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PEDIATRICS
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ONCOLOGY
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OB/GYN
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ORTHOPEDICS
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PSYCHIATRY
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OPERATING ROOM
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RRT
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EMERGENCY ROOM
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CRT
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TRAUMA CENTER
LEVEL 1
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COMMUNITY ER
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RURAL ER
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Rating Stars
(Click)
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AGE APPROPRIATE CARE
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1
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2
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3
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4
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Newborn/Neonatal (birth –
30 days)
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Infant (30 days-1 year)
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Toddler (1-3 years)
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Preschool (3-5 years)
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School Age Children (5-12
years)
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Adolescent (12-17 years)
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Young Adults (18-44 years)
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Middle Adults (45-64 years)
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Older Adults (>65 years)
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