Operation Room / Circulate Skills Checklist

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WORK SETTING EXPERIENCE:

Rank each of the following sections on a scale of 1 to 3:

1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently *
Inpatient Acute Care Facility123
Trauma Center123
Academic/Teaching Facility123
Outpatient Care Facility123
Long term care/Skilled Nursing123
Clinic/Ambulatory123
Home Health Setting123
GENERAL SKILLS EXPERIENCE:

Rank each of the following sections on a scale of 1 to 3:

1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently *
Awareness of HCAHPS123
Cardiac arrest / adult CPR123
Cardiac arrest / infant-child CPR123
Advanced directives123
Patient / family teaching123
Lift / transfer devices123
Specialty beds123
Restrictive devices (restraints)123
End of life care / palliative care123
Automated Medication Dispensing System, Pyxis, Omnicell, or other123
Bar coding for medication administration123
Diabetic management in the OR123
National Patient Safety Goals123
Accurate patient identification123
Effective communication123
Time out protocol123
Interpretation & communication of lab values123
Medication administration123
Labeling (medications & specimens)123
Medication reconciliation123
Anticoagulation therapy123
Monitoring conscious sedation123
Sedation / Anesthesia123
Infection control123
Universal precautions123
Isolation123
Minimize risk for falls123
Prevention of pressure ulcers123
CIRCULATE: GENERAL SURGERY EXPERIENCE:

Rank each of the following sections on a scale of 1 to 3:

1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently *
Abdominal perineal resection123
Adrenalectomy bariatric surgery (gastric bypass)123
Bowel resection123
Cholecystectomy / cholangiogram123
Colostomy / ileostomy123
Gastrectomy123
Hemicolectomy123
Hepatic resection123
Herniorrhaphy- femoral / inguinal123
Hiatal herniorrhaphy123
Pancreatectomy123
Organ procurement123
Radical mastectomy123
Saphenous vein ligation / stripping123
Splenectomy123
Thyroidectomy123
Tracheostomy123
Vagotomy123
Familiarity with pediatric procedures123
CIRCULATE: GYNECOLOGY EXPERIENCE:

Rank each of the following sections on a scale of 1 to 3:

1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently *
Caesarean section123
Dilation & curettage123
Hysterectomy - vaginal123
Hysterectomy - abdominal123
Radium insertion123
Salpingo - oophorectomy123
Shirodkar procedure123
Termination of pregnancy123
Tubal ligation123
CIRCULATE: ENDOSCOPIC PROCEDURES EXPERIENCE:

Rank each of the following sections on a scale of 1 to 3:

1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently *
Bronchoscopy123
Colonoscopy123
Culdoscopy123
Cystoscopy123
Esophagoscopy123
Gastroscopy123
Hysteroscopy123
CIRCULATE: LAPAROSCOPIC PROCEDURES EXPERIENCE:

Rank each of the following sections on a scale of 1 to 3:

1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently *
Appendectomy123
Cholecystectomy123
Colon resection123
Gastric bypass123
Hernia repair123
Nephrectomy123
Prostatectomy123
Sinus surgery123
Salpingo- oophorectomy123
Splenectomy123
Tubal ligation123
Vaginal hysterectomy123
Vitrectomy123
Laryngoscopy123
Mediastinoscopy123
Pelviscopy123
Sigmoidoscopy123
Thoracoscopy123
Whipple123
Nissen fundoplication123
CIRCULATE: UROLOGY EXPERIENCE:

Rank each of the following sections on a scale of 1 to 3:

1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently *
Circumcision123
Cystoscopy / ureteroscopy123
Cystectomy123
Hypospadias repair123
Implants123
Lithotripsy123
Nephrectomy123
Orchiectomy123
Prostatectomy123
Ureterolithotomy123
TURP123
PVP - Photo Vaporization of Prostate123
Vasectomy123
CIRCULATE: ORTHOPEDIC EXPERIENCE:

Rank each of the following sections on a scale of 1 to 3:

1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently *
Achilles tendon repair123
Amputation123
Arthroscopy / anthrotomy123
Closed pinning & reduction of extremities123
External compression devices123
Hip compression nails & lag screws123
Total joint replacement - knee123
Total joint replacement - hip123
Total joint replacement - shoulder123
Spica cast123
ORIF - shoulder, hip, humerus123
Repair of dislocation123
Patellectomy123
Tendon implants & reanastomosis123
CIRCULATE: NEUROLOGY EXPERIENCE:

Rank each of the following sections on a scale of 1 to 3:

1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently *
Kyphoplasty123
A-V malformation123
Laparoscopic spine procedures123
Burr holes for subdural hematoma123
Carotid ligation123
Cervical sympathectomy123
Cranioplasty123
Craniotomy123
Disectomy / laminectomy123
Halo traction application123
Insertion of nerve stimulator123
Myelo- meningocele repair123
Shunt procedure VP/VA/LP123
Spinal fusions123
Ventriculostomy123
CIRCULATE: PLASTICS EXPERIENCE:

Rank each of the following sections on a scale of 1 to 3:

1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently *
Abdominal lipectomy123
Blepharoplasty123
Face lift123
Mammoplasty123
Augmentation123
Reduction123
Liposuction123
Otoplasty123
Scar revisions123
Skin grafting123
CIRCULATE: OPHTHALMOLOGY EXPERIENCE:

Rank each of the following sections on a scale of 1 to 3:

1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently *
Cataract extraction123
IOL implants123
Corneal transplant123
Orbital implant123
Enucleation123
Repair orbital blowout fracture123
Repair of retinal detachment123
Scleral buckle123
CIRCULATE: EAR, NOSE & THROAT EXPERIENCE:

Rank each of the following sections on a scale of 1 to 3:

1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently *
Caldwell-luc123
Cleft lip / palate repair123
Laryngectomy123
Radical neck123
Tonsillectomy & adenoidectomy123
Mandibulectomy123
Mastoidectomy123
Rhinoplasty / septoplasty123
Sinusotomy123
CIRCULATE: VASCULAR EXPERIENCE:

Rank each of the following sections on a scale of 1 to 3:

1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently *
Angiography123
A-V access graft123
Aortic aneurysm: abdominal123
Peripheral vascular bypass procedures123
Endarterectomy: carotid123
Thrombectomy123
Embolectomy123
Vena cava ligation123
CIRCULATE: ENDOVASCULAR EXPERIENCE: 

Rank each of the following sections on a scale of 1 to 3:

1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently *
Endoluminal AAA123
Carotid revascularization endarterectomy123
Cerebral aneurysm repair123
CIRCULATE: THORACIC / CARDIOVASCULAR EXPERIENCE:

Rank each of the following sections on a scale of 1 to 3:

1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently *
Aortic femoral bypass graft123
Femoral popliteal bypass123
Pacemaker implantation / explanation123
Care of patients with pacemaker123
Care of patients with intra-aortic balloon pump123
Septal defects, ASV, VSD123
Coronary Artery Bypass & Graft (CABG) on pump123
Coronary Artery Bypass & Graft (CABG) off pump123
Valve replacement / repair123
Aortic aneurysm123
Thoracotomy / lobectomy123
Endoscopic vein harvesting123
Maze procedure123
Thoracic aneurysm123
CIRCULATE: TRANSPLANT EXPERIENCE:

Rank each of the following sections on a scale of 1 to 3:

1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently *
Bone123
Corneal123
Harvesting123
Heart/lung123
Kidney123
Liver123
Multi organ123
Pancreas123
Skin123
CIRCULATE: TRAUMA EXPERIENCE:

Rank each of the following sections on a scale of 1 to 3:

1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently *
Burns123
Gunshot / stab wounds123
Motor vehicle accidents123
Traumatic amputations123
CIRCULATE: EQUIPMENT EXPERIENCE:

Rank each of the following sections on a scale of 1 to 3:

1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently *
Argon beam coagulator123
Camera / video systems123
Cell saver123
Cidex soak123
Cryo-ophthalmic unit123
Cavitron Ultrasonic Surgical Aspirator (CUSA)123
Hypo / hyperthermia unit123
Drill and saws123
Electrosurgical unit123
Fiber optic luminator123
Cavitron123
Autoclave123
Fracture tables123
Harmonic scalpel123
Ligasure123
Stapling devices123
Mesh graft / dermatone123
Microscopes123
Nitrogen tank123
Pneumatic tourniquet123
Stealth123
Steris unit123
Pulsevac irrigation123
Autotransfusion system123
Laser equipment123
Care of scopes & fiberoptic equipment123
Venodyne robotics (Da Vinci)123
CIRCULATE: AGE-SPECIFIC EXPERIENCE:

Rank each of the following sections on a scale of 1 to 3:

1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently *
Newborn / neonate (birth-30 days)123
Infant (31 days-1 year)123
Toddler (ages 2-3 years)123
Preschool (ages 4-5 years)123
School age (ages 6-12 years)123
Adolescent (ages 13-21 years)123
Young adult (ages 22-39 years)123
Adult (ages 40-64 years)123
Older adult (ages 65-79 years)123
Elderly (ages 80+ years)123

Attestation

ATTESTATION: *