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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

General Skills Experience
(1) Limited or no experience
(2) Experienced, but may need review or supervision
(3) Able to function independently *
 123
Awareness of HCAHPS
Cardiac arrest / adult CPR
Cardiac arrest / infant-child CPR
Advanced directives
Patient / family teaching
Lift / transfer devices
Specialty beds
Restrictive devices (restraints)
End of life care / palliative care
Automated Medication Dispensing System, Pyxis, Omnicell, or other
Bar coding for medication administration
Diabetic management in the OR
National Patient Safety Goals
Accurate patient identification
Effective communication
Time out protocol
Interpretation & communication of lab values
Medication administration
Labeling (medications & specimens)
Medication reconciliation
Anticoagulation therapy
Monitoring conscious sedation
Sedation / Anesthesia
Infection control
Universal precautions
Isolation
Minimize risk for falls
Prevention of pressure ulcers
Scrub: General Surgery Experience
(1) Limited or no experience
(2) Experienced, but may need review or supervision
(3) Able to function independently *
 123
Abdominal perineal resection
Adrenalectomy bariatric surgery (gastric bypass)
Bowel resection
Cholecystectomy / cholangiogram
Colostomy / ileostomy
Gastrectomy
Hemicolectomy
Hepatic resection
Herniorrhaphy- femoral / inguinal
Hiatal herniorrhaphy
Pancreatectomy
Organ procurement
Radical mastectomy
Saphenous vein ligation / stripping
Splenectomy
Thyroidectomy
Tracheostomy
Vagotomy
Familiarity with pediatric procedures
Scrub: Gynecology Experience
(1) Limited or no experience
(2) Experienced, but may need review or supervision
(3) Able to function independently *
 123
Caesarean section
Dilation & curettage
Hysterectomy - vaginal
Hysterectomy - abdominal
Radium insertion
Salpingo- oopherectomy
Shirodkar procedure
Termination of pregnancy
Tubal litigation
Vaginectomy
Scrub: Endoscopic Procedures Experience
(1) Limited or no experience
(2) Experienced, but may need review or supervision
(3) Able to function independently *
 123
Bronchoscopy
Colonoscopy
Culdoscopy
Cystoscopy
Esophagoscopy
Gastroscopy
Hysteroscopy
Scrub: Laparoscopic Procedures Experience
(1) Limited or no experience
(2) Experienced, but may need review or supervision
(3) Able to function independently *
 123
Appendectomy
Cholecystectomy
Colon resection
Gastric bypass
Hernia repair
Nephrectomy
Prostatectomy
Sinus surgery
Salpingo- oophorectomy
Splenectomy
Tubal ligation
Vaginal hysterectomy
Vitrectomy
Laryngoscopy
Mediastinoscopy
Pelviscopy
Sigmoidoscopy
Thoracoscopy
Whipple
Nissen fundoplication
Scrub: Urology Experience
(1) Limited or no experience
(2) Experienced, but may need review or supervision
(3) Able to function independently *
 123
Circumcision
Cystoscopy/ ureteroscopy
Cystectomy
Hypospadias repair
Implants
Lithotripsy
Nephrectomy
Orchiectomy
Prostatectomy
Ureterolithotomy
TURP
PVP - Photo Vaporization of Prostate
Vasectomy
Scrub: Orthopedic Experience
(1) Limited or no experience
(2) Experienced, but may need review or supervision
(3) Able to function independently *
 123
Achilles tendon repair
Amputation
Arthroscopy / anthrotomy
Closed pinning & reduction of extremities
External compression devices
Hip compression nails & lag screws
Total joint replacement - knee
Total joint replacement - hip
Total joint replacement - shoulder
Spica cast
ORIF - shoulder, hip, humerus
Repair of dislocation
Patellectomy
Tendon implants & reanastomosis
Scrub: Neurology Experience
(1) Limited or no experience
(2) Experienced, but may need review or supervision
(3) Able to function independently *
 123
Kyphoplasty
A-V malformation
Laparoscopic spine procedures
Burr holes for subdural hematoma
Carotid ligation
Cervical sympathectomy
Cranioplasty
Craniotomy
Disectomy / laminectomy
Halo traction application
Insertion of nerve stimulator
Myelo- meningocele repair
Shunt procedure VP/VA/LP
Spinal fusions
Ventriculostomy
Scrub: Plastics Experience
(1) Limited or no experience
(2) Experienced, but may need review or supervision
(3) Able to function independently *
 123
Abdominal lipectomy
Blepharoplasty
Face lift
Mammoplasty
Augmentation
Reduction
Liposuction
Otoplasty
Scar revisions
Skin grafting
Scrub: Ophthalmology Experience
(1) Limited or no experience
(2) Experienced, but may need review or supervision
(3) Able to function independently *
 123
Cataract extraction
IOL implants
Corneal transplant
Orbital implant
Enucleation
Repair orbital blowout fracture
Repair of retinal detachment
Scleral buckle
Scrub: Ear, Nose & Throat Experience
(1) Limited or no experience
(2) Experienced, but may need review or supervision
(3) Able to function independently *
 123
Caldwell-luc
Cleft lip / palate repair
Laryngectomy
Radical neck
Tonsillectomy & adenoidectomy
Mandibulectomy
Mastoidectomy
Rhinoplasty / septoplasty
Sinusotomy
Scrub: Vascular Experience
(1) Limited or no experience
(2) Experienced, but may need review or supervision
(3) Able to function independently *
 123
Angiography
A-V access graft
Aortic aneurysm: abdominal
Peripheral vascular bypass procedures
Endarterectomy: carotid
Thrombectomy
Embolectomy
Vena cava ligation
Scrub: Endovascular Experience
(1) Limited or no experience
(2) Experienced, but may need review or supervision
(3) Able to function independently *
 123
Endoluminal AAA
Carotid revascularization endarterectomy
Cerebral aneurysm repair
Scrub: Thoracic / Cardiovascular Experience
(1) Limited or no experience
(2) Experienced, but may need review or supervision
(3) Able to function independently *
 123
Aortic femoral bypass graft
Femoral popliteal bypass
Pacemaker implantation / explanation
Care of patients with pacemaker
Care of patient with intra-aortic balloon pump
Septal defects, ASV, VSD
Coronary Artery Bypass & Graft (CABG) on pump
Coronary Artery Bypass & Graft (CABG) off pump
Valve replacement / repair
Aortic aneurysm
Thoracotomy / lobectomy
Endoscopic vein harvesting
Maze procedure
Thoracic aneurysm
Scrub: Transplant Experience
(1) Limited or no experience
(2) Experienced, but may need review or supervision
(3) Able to function independently *
 123
Bone
Corneal
Harvesting
Heart/lung
Kidney
Liver
Multi organ
Pancreas
Skin
Scrub: Trauma Experience
(1) Limited or no experience
(2) Experienced, but may need review or supervision
(3) Able to function independently *
 123
Burns
Gunshot / stab wounds
Motor vehicle accidents
Traumatic amputations
Scrub: Equipment Experience
(1) Limited or no experience
(2) Experienced, but may need review or supervision
(3) Able to function independently *
 123
Argon beam coagulator
Camera / video systems
Cell saver
Cidex soak
Cryo- ophthalmic unit
Cavitron Ultrasonic Surgical Aspirator (CUSA)
Hypo / hyperthermia unit
Drill and saws
Electrosurgical unit
Fiber optic luminator
Cavitron
Autoclave
Fracture tables
Harmonic scalpel
Ligasure
Stapling devices
Mesh graft / dermatone
Microscopes
Nitrogen tank
Pneumatic tourniquet
Stealth
Steris unit
Pulsevac irrigation
Autotransfusion system
Laser equipment
Care of scopes & fiberoptic equipment
Venodyne robotics (Da Vinci)
Scrub: Age Specific Competencies Experience
(1) Limited or no experience
(2) Experienced, but may need review or supervision
(3) Able to function independently *
 123
Newborn / neonate (birth-30 days)
Infant (31 days-1 year)
Toddler (2-3 years)
Preschool (ages 4-5 years)
School age (ages 6-12 years)
Adolescents (ages 13-21 years)
Young adult (ages 22-39 years)
Adults (ages 40-64 years)
Older adult (ages 65-79 years)
Elderly (80+ years)
ATTESTATION *