Surgical Technologist 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
Patient/family teaching123
Restrictive devices (restraints)123
Lift/transfer devices123
Patient positioning123
National Patient Safety Goals123
Accurate patient identification123
Effective communication123
Infection control123
Universal precautions123
Care of the patient in isolation123
Medication administration on sterile field123
Labeling (medications & specimens) on sterile field123
Time out protocol123
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
Adrenalectomy123
Bowel resection123
Cholecystectomy/cholangiogram123
Colostomy/ileostomy123
Gastrectomy123
Herniorrhaphy-femoral/inguinal123
Hiatal herniorrhaphy transabdominal123
Pancreatectomy123
Organ procurement123
Radical mastectomy123
Saphenous vein ligation/stripping123
Splenectomy123
Thyroidectomy123
Vagotomy123
Breast biopsy123
Mastectomy123
Common bile duct explorations123
Open appendectomy123
Jejunostomy tube replacement123
Liver biopsy123
Excision of lipoma123
Parathyroidectomy123
Parathyroidectomy with transplant123
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
Shirodkar procedure123
Termination of pregnancy123
Tubal ligation123
Vaginectomy123
Vaginal anterior repair surgery123
Vaginal posterior repair surgery123
Salpingo-oopherectomy123
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
Endo/colonoscopy123
Culdoscopy123
Cystoscopy123
Esophagoscopy123
Gastroscopy123
Hysteroscopy123
LAPAROSCOPIC PROCEDURES:

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
Hernia repair123
Salpingo-oophorectomy123
Tubal ligation123
Vaginal hysterectomy123
Laryngoscopy123
Mediastinoscopy123
Pelviscopy123
Sigmoidoscopy123
Thoracoscopy123
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
Vasectomy123
Implants - penile123
Uteroplasty123
Transurethral Resection of Bladder Tumor (TURBT)123
Testicular tortion123
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/arthrotomy123
Closed pinning & reduction of extremities123
External compression devices123
Hip compression nails & lag screws123
Total joint replacement - knee, hip, shoulder123
Spica cast123
ORIF - shoulder, hip, humerus123
Repair of dislocation123
Patellectomy123
Tendon implants & reanastomosis123
External fixator123
ORIF - ankle123
ORIF - radius/ulna123
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 *
A-V malformation123
Laparoscopic spine procedures123
Burr holes for subdural hematoma123
Carotid ligation123
Cervical sympathectomy123
Cranioplasty123
Craniotomy123
Discectomy/laminectomy123
Halo traction application123
Insertion of nerve stimulator devices123
Myelomeningocele repair123
Shunt procedure VP/ VA/LP123
Spinal fusions123
Ventriculostomy123
Kyphoplasty123
Spinal cord stimulator insertion123
Cervical laminectomy123
Lumbar laminectomy123
Spinal fusion - cervical123
Spinal fusion - lumbar123
Panniculectomy123
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
Reconstructive123
Liposuction123
Otoplasty123
Scar revisions123
Skin grafting123
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
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
Radial neck disection/resection123
Tonsillectomy & adenoidectomy123
Mandibulectomy123
Mastoidectomy123
Rhinoplasty/septoplasty123
Sinusotomy123
Tracheostomy123
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
Endarterectomy: carotid123
Peripheral vascular bypass procedures123
Thrombectomy123
Embolectomy123
Vena cava ligation123
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/explantation123
Care of patients with pacemakers123
Care of patients with IABP123
Septal defects, ASV, VSD123
Coronary artery bypass graft123
Valve replacement123
Aortic aneurysm: thoracic123
Thoracotomy123
Lobectomy123
Rib resection123
Endoscopic vein harvesting123
Off pump bypass123
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
Bone marrow123
Corneal123
Harvesting123
Heart/lung123
Kidney123
Liver123
Multi organ123
Pancreas123
Skin123
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 wound123
Motor vehicle accidents123
Traumatic amputations123
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 *
Camera/video systems123
Cell saver123
Cidex soak123
Cryo-ophthalmic unit123
CUSA123
Drills & saws123
Electrosurgical unit123
Fiber optic laminator123
Cavitron123
Autoclave123
Fracture tables123
Stapling devices123
Mesh graft/dermatone123
Microscopes123
Nitrogen tank123
Pneumatic tourniquet123
Steris unit123
Pulsevac irrigation123
Autotransfusion systems123
Laser equipment123
Care of scopes & fiberoptic equipment123
Venodyne robotics (DaVinci)123
AGE-SPECIFIC COMPETENCIES 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: *