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SURGICAL FIRST ASSIST
SKILLS CHECKLIST
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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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Work Settings
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1
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2
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3
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4
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Inpatient hospital
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Level 1 trauma center
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Outpatient setting
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Rating Stars
(Click)
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General 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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Advanced directives
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Awareness of HCAHPS
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Patient/family teaching
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Restrictive devices
(restraints)
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Lift/transfer devices
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Patient positioning
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National Patient Safety
Goals
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Accurately identify
patient/surgical site verification
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Effective communication
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Interpretation &
timely communication of lab values
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Labeling (medications
& specimens)
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Medication reconciliation
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Anticoagulant therapy
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MDRO HAI
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Hand hygiene WHO/CDC
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CLABSI infections
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CAUTI prevention
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Identify patient suicide
risk
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Universal protocol
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Surg site infection
control
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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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Abdominal perineal
resection
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Adrenalectomy
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Bowel resection
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Cholecystectomy/cholangiogram
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Colostomy/ileostomy
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Gastrectomy
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Herniorrhaphy-femoral/inguinal
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Hiatal herniorrhaphy
transabdominal
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Pancreatectomy
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Organ procurement
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Radical mastectomy
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Saphenous vein
ligation/stripping
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Splenectomy
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Thyroidectomy
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Vagotomy
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Rating Stars
(Click)
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Gynecology
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1
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2
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3
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4
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Caesarean section
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Dilation & curettage
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Hysterectomy - vaginal
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Hysterectomy - abdominal
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Radium insertion
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Shirodkar procedure
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Termination of pregnancy
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Tubal ligation
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Vaginectomy
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Rating Stars
(Click)
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Endoscopic Procedures
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1
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2
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3
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4
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Bronchoscopy
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Endo/colonoscopy
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Culdoscopy
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Cystoscopy
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Esophagoscopy
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Gastroscopy
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Hysteroscopy
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Laparoscopic Procedures
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Appendectomy
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Cholecystectomy
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Colon resection
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Hernia repair
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Salpingo-oophorectomy
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Tubal ligation
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Vaginal hysterectomy
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Laryngoscopy
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Mediastinoscopy
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Pelviscopy
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Sigmoidoscopy
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Thoracoscopy
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Rating Stars
(Click)
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Urology
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1
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2
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3
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4
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Circumcision
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Cystoscopy/ureteroscopy
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Cystectomy
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Hypospadias repair
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Implants
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Lithotripsy
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Nephrectomy
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Orchiectomy
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Prostatectomy
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Ureterolithotomy
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TURP
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Vasectomy
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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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Achilles tendon repair
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Amputation
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Arthroscopy/anthrotomy
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Closed pinning &
reduction of extremities
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External compression
devices
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Hip compression nails
& lag screws
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Total joint replacement -
knee, hip, shoulder
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Spica cast
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ORIF - shoulder, hip,
humerus
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Repair of dislocation
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Patellectomy
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Tendon implants &
reanastomosis
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Rating Stars
(Click)
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Neurology
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1
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2
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3
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4
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A-V malformation
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Laparoscopic spine
procedures
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Burr holes for subdural
hematoma
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Carotid ligation
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Cervical sympathectomy
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Cranioplasty
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Craniotomy
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Disectomy/laminectomy
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Halo traction application
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Insertion of nerve
stimulator devices
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Myelomeningocele repair
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Shunt procedure VP/VA/LP
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Spinal fusions
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Ventriculostomy
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Rating Stars
(Click)
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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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Abdominal lipectomy
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Blepharoplasty
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Face lift
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Mammoplasty
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Augmentation
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Reduction
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Reconstructive
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Liposuction
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Otoplasty
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Scar revisions
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Skin grafting
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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 extraction
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IOL implants
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Corneal transplant
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Orbital implant
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Enucleation
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Repair orbital blowout
fracture
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Repair of retinal
detachment
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Scleral buckle
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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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Caldwell-luc
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Cleft lip/palate repair
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Laryngectomy
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Radial neck
disection/resection
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Tonsillectomy &
adenoidectomy
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Mandibulectomy
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Mastoidectomy
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Rhinoplasty/septoplasty
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Sinusotomy
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Tracheostomy
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Rating Stars
(Click)
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Vascular
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1
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2
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3
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4
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Angiography
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A-V access graft
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Aortic aneurysm: abdominal
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Endarterectomy: carotid
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Peripheral vascular bypass
procedures
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Thrombectomy
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Embolectomy
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Vena cava ligation
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Rating Stars
(Click)
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Thoracic/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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Aortic femoral bypass
graft
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Femoral popliteal bypass
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Pacemaker
implantation/explantation
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Care of patients with
pacemakers
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Care of patients with IABP
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Septal defects, ASV, VSD
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Coronary artery bypass
graft
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Valve replacement
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Aortic aneurysm: thoracic
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Thoracotomy
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Lobectomy
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Rib resection
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Endoscopic vein harvesting
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Off pump bypass
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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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Bone
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Bone marrow
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Corneal
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Harvesting
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Heart/lung
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Kidney
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Liver
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Multi organ
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Pancreas
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Skin
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Rating Stars
(Click)
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Trauma
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1
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2
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3
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4
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Burns
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Gunshot/stab wound
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Motor vehicle accidents
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Traumatic amputations
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Rating Stars
(Click)
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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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Camera/video systems
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Cell saver
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Cidex soak
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Cryo ophthalmic unit
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CUSA
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Drills & saws
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Electrosurgical unit
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Fiber optic laminator
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Cavitron
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Autoclave
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Fracture tables
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Stapling devices
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Mesh graft/dermatone
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Microscopes
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Nitrogen tank
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Pneumatic tourniquet
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Steris unit
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Pulsevac irrigation
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Autotransfusion systems
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Laser equipment
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Care of scopes &
fiberoptic equipment
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Venodyne robotics (Da
Vinci)
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Rating Stars
(Click)
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Surgical First Assist
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1
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2
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3
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4
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Position patient per
surgeon's order
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Pressure point padding
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Apply tourniquest as
ordered
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Protect from nerve damage
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Thermorgulation
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Use of fracture table
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Use of head stabilizer
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Use of body stabilizer
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Use of c-arm extensions
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Skin assessmnet
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Use of retractors
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Packing with sponges
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Digital manipulation of
tissue
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Suctioning, irrigaiton,
sponging
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Manipultaion of surgical
materials (loops, tags)
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Clamping/cauterizing
vessels or tissues
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Tying/ligating clamped
vessles or tissues
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Apply hemostatic clips
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Place local hemostatic
agents
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Direct digital pressure
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Assist in volume
replacement
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Assist in autotransfusion
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Suturing all wound layers
including muscle & fascia
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Wound dressing: liquid or
spray occlusive
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Absorbent immobilizing
dressing
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Assist to secure drainage
system to tissue
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Insert/remove Foley
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Drape patient
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Electrocautery mono
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Electrocautery bipolar
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Cut tissue
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Harvest saphenous vein,
including skin incision
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|
|
|
Dissect common femoral
artery and bifurcate
|
|
|
|
|
|
|
|
Insert drainage tubes
|
|
|
|
|
|
|
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)
|
|
|
|
|
|