Cardiovascular Operating Room Circulate/Scrub (CVOR) Skills Checklist

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Last Name: *

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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

CARDIAC EXPERIENCE: CIRCULATE

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 *

DaVinci Procedures	123
Aortic Valve Replacement	123
Mitral Valve Repair/Replacement	123
Multiple Valve Transposition	123
Coronary Artery By Pass	123
Pericardial Window	123
Septal Defects	123
Ventricular aneurysm repair	123
Intra-Aortic Ballon insertion	123
Bring Back Heart	123
Aortic Arch Replacement	123
Aortic Valve Conduit	123
Thoraco Approach Mid-Cab	123
Heartport or Similar CABG	123
Mechanical Heart/ LVAD	123
Chamberlain Procedure	123
Femoral Artery Cannulation	123
Gastric Artery Harvest	123
Endoscopic Vein Harvest	123
Saphenous Vein Harvest	123
AICD Insertion	123
Radial Vein Harvest	123
Pacemaker Insertion	123
AV Shunt	123
Femoral-Popliteal By-Pass Graf	123
Thrombectomy	123
Abdominal Aortic Aneurysm	123
Carotid Endarterectomy	123
Pediatric Hearts	123
Tetrology of Fallot	123
Organ procurement	123

CARDIAC EXPERIENCE: SCRUB

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 *

DaVinci Procedures	123
Aortic Valve Replacement	123
Mitral Valve Repair/Replacement	123
Multiple Valve Transposition	123
Coronary Artery By Pass	123
Pericardial Window	123
Septal Defects	123
Ventricular aneurysm repair	123
Intra-Aortic Ballon insertion	123
Bring Back Heart	123
Aortic Arch Replacement	123
Aortic Valve Conduit	123
Thoraco Approach Mid-Cab	123
Heartport or Similar CABG	123
Mechanical Heart/ LVAD	123
Chamberlain Procedure	123
Femoral Artery Cannulation	123
Gastric Artery Harvest	123
Endoscopic Vein Harvest	123
Saphenous Vein Harvest	123
AICD Insertion	123
Radial Vein Harvest	123
Pacemaker Insertion	123
AV Shunt	123
Femoral-Popliteal By-Pass Graf	123
Thrombectomy	123
Abdominal Aortic Aneurysm	123
Carotid Endarterectomy	123
Pediatric Hearts	123
Tetrology of Fallot	123
Organ procurement	123

VASCULAR EXPERIENCE: CIRCULATE

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 *

Carotid Endarterectomy	123
Abdominal Aoric Aneurysm	123
Femoral-Popliteal By-Pass Graft (Insitu)	123
AV Shunt	123
Portacath, Tesio, Hickman	123
Femoral-Popliteal By-Pass Graft (Graph)	123
Thrombecomy	123
Pacemaker Insertion	123
Arterial Stenting	123
Subclavian/Carotid By-Pass	123
Intra-Operative Angioplasty	123

VASCULAR EXPERIENCE: SCRUB

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 *

Carotid Endarterectomy	123
Abdominal Aoric Aneurysm	123
Femoral-Popliteal By-Pass Graft (Insitu)	123
AV Shunt	123
Portacath, Tesio, Hickman	123
Femoral-Popliteal By-Pass Graft (Graph)	123
Thrombecomy	123
Pacemaker Insertion	123
Arterial Stenting	123
Subclavian/Carotid By-Pass	123
Intra-Operative Angioplasty	123

THORACIC CARDIOVASCULAR EXPERIENCE: CIRCULATE

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 Aortic Aneurysm	123
Aortic-Femoral Bypass Graft	123
Thoracotomy	123
Thoracoscopy	123
Mediastinoscopy	123
Lobectomy	123
Carotid Endarterectomy	123
AV Shunt/Graft	123

THORACIC CARDIOVASCULAR EXPERIENCE: SCRUB

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 Aortic Aneurysm	123
Aortic-Femoral Bypass Graft	123
Thoracotomy	123
Thoracoscopy	123
Mediastinoscopy	123
Lobectomy	123
Carotid Endarterectomy	123
AV Shunt/Graft	123

CIRCULATE/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. *