Operation Room / Scrub Skills Checklist

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Today's Date: * +

First Name: *

Last Name: *

Mobile Phone Number: *

Email Address: *

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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 Facility	123
Trauma Center	123
Academic/Teaching Facility	123
Outpatient Care Facility	123
Long term care/Skilled Nursing	123
Clinic/Ambulatory	123
Home Health Setting	123

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 HCAHPS	123
Cardiac arrest / adult CPR	123
Cardiac arrest / infant-child CPR	123
Advanced directives	123
Patient / family teaching	123
Lift / transfer devices	123
Specialty beds	123
Restrictive devices (restraints)	123
End of life care / palliative care	123
Automated Medication Dispensing System, Pyxis, Omnicell, or other	123
Bar coding for medication administration	123
Diabetic management in the OR	123
National Patient Safety Goals	123
Accurate patient identification	123
Effective communication	123
Time out protocol	123
Interpretation & communication of lab values	123
Medication administration	123
Labeling (medications & specimens)	123
Medication reconciliation	123
Anticoagulation therapy	123
Monitoring conscious sedation	123
Sedation / Anesthesia	123
Infection control	123
Universal precautions	123
Isolation	123
Minimize risk for falls	123
Prevention of pressure ulcers	123

SCRUB: 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 resection	123
Adrenalectomy bariatric surgery (gastric bypass)	123
Bowel resection	123
Cholecystectomy / cholangiogram	123
Colostomy / ileostomy	123
Gastrectomy	123
Hemicolectomy	123
Hepatic resection	123
Herniorrhaphy- femoral / inguinal	123
Hiatal herniorrhaphy	123
Pancreatectomy	123
Organ procurement	123
Radical mastectomy	123
Saphenous vein ligation / stripping	123
Splenectomy	123
Thyroidectomy	123
Tracheostomy	123
Vagotomy	123
Familiarity with pediatric procedures	123

SCRUB: 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 section	123
Dilation & curettage	123
Hysterectomy - vaginal	123
Hysterectomy - abdominal	123
Radium insertion	123
Salpingo- oopherectomy	123
Shirodkar procedure	123
Termination of pregnancy	123
Tubal litigation	123
Vaginectomy	123

SCRUB: 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 *

Bronchoscopy	123
Colonoscopy	123
Culdoscopy	123
Cystoscopy	123
Esophagoscopy	123
Gastroscopy	123
Hysteroscopy	123

SCRUB: 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 *

Appendectomy	123
Cholecystectomy	123
Colon resection	123
Gastric bypass	123
Hernia repair	123
Nephrectomy	123
Prostatectomy	123
Sinus surgery	123
Salpingo- oophorectomy	123
Splenectomy	123
Tubal ligation	123
Vaginal hysterectomy	123
Vitrectomy	123
Laryngoscopy	123
Mediastinoscopy	123
Pelviscopy	123
Sigmoidoscopy	123
Thoracoscopy	123
Whipple	123
Nissen fundoplication	123

SCRUB: 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 *

Circumcision	123
Cystoscopy/ ureteroscopy	123
Cystectomy	123
Hypospadias repair	123
Implants	123
Lithotripsy	123
Nephrectomy	123
Orchiectomy	123
Prostatectomy	123
Ureterolithotomy	123
TURP	123
PVP - Photo Vaporization of Prostate	123
Vasectomy	123

SCRUB: 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 repair	123
Amputation	123
Arthroscopy / anthrotomy	123
Closed pinning & reduction of extremities	123
External compression devices	123
Hip compression nails & lag screws	123
Total joint replacement - knee	123
Total joint replacement - hip	123
Total joint replacement - shoulder	123
Spica cast	123
ORIF - shoulder, hip, humerus	123
Repair of dislocation	123
Patellectomy	123
Tendon implants & reanastomosis	123

SCRUB: 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 *

Kyphoplasty	123
A-V malformation	123
Laparoscopic spine procedures	123
Burr holes for subdural hematoma	123
Carotid ligation	123
Cervical sympathectomy	123
Cranioplasty	123
Craniotomy	123
Disectomy / laminectomy	123
Halo traction application	123
Insertion of nerve stimulator	123
Myelo- meningocele repair	123
Shunt procedure VP/VA/LP	123
Spinal fusions	123
Ventriculostomy	123

SCRUB: 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 lipectomy	123
Blepharoplasty	123
Face lift	123
Mammoplasty	123
Augmentation	123
Reduction	123
Liposuction	123
Otoplasty	123
Scar revisions	123
Skin grafting	123

SCRUB: 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 extraction	123
IOL implants	123
Corneal transplant	123
Orbital implant	123
Enucleation	123
Repair orbital blowout fracture	123
Repair of retinal detachment	123
Scleral buckle	123

SCRUB: 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-luc	123
Cleft lip / palate repair	123
Laryngectomy	123
Radical neck	123
Tonsillectomy & adenoidectomy	123
Mandibulectomy	123
Mastoidectomy	123
Rhinoplasty / septoplasty	123
Sinusotomy	123

SCRUB: 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 *

Angiography	123
A-V access graft	123
Aortic aneurysm: abdominal	123
Peripheral vascular bypass procedures	123
Endarterectomy: carotid	123
Thrombectomy	123
Embolectomy	123
Vena cava ligation	123

SCRUB: 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 AAA	123
Carotid revascularization endarterectomy	123
Cerebral aneurysm repair	123

SCRUB: 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 graft	123
Femoral popliteal bypass	123
Pacemaker implantation / explanation	123
Care of patients with pacemaker	123
Care of patient with intra-aortic balloon pump	123
Septal defects, ASV, VSD	123
Coronary Artery Bypass & Graft (CABG) on pump	123
Coronary Artery Bypass & Graft (CABG) off pump	123
Valve replacement / repair	123
Aortic aneurysm	123
Thoracotomy / lobectomy	123
Endoscopic vein harvesting	123
Maze procedure	123
Thoracic aneurysm	123

SCRUB: 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 *

Bone	123
Corneal	123
Harvesting	123
Heart/lung	123
Kidney	123
Liver	123
Multi organ	123
Pancreas	123
Skin	123

SCRUB: 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 *

Burns	123
Gunshot / stab wounds	123
Motor vehicle accidents	123
Traumatic amputations	123

SCRUB: 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 coagulator	123
Camera / video systems	123
Cell saver	123
Cidex soak	123
Cryo- ophthalmic unit	123
Cavitron Ultrasonic Surgical Aspirator (CUSA)	123
Hypo / hyperthermia unit	123
Drill and saws	123
Electrosurgical unit	123
Fiber optic luminator	123
Cavitron	123
Autoclave	123
Fracture tables	123
Harmonic scalpel	123
Ligasure	123
Stapling devices	123
Mesh graft / dermatone	123
Microscopes	123
Nitrogen tank	123
Pneumatic tourniquet	123
Stealth	123
Steris unit	123
Pulsevac irrigation	123
Autotransfusion system	123
Laser equipment	123
Care of scopes & fiberoptic equipment	123
Venodyne robotics (Da Vinci)	123

SCRUB: 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: *

I certify that the information provide above accurately reflects my experience in each of the clinical areas identified within the past three years.

If you agree with the Attestation above, please electronically sign your name. *