Operating Room Nursing Skills Checklist One program to handle all talent management needs from acquisition to development Personal Information This field is hidden when viewing the formOverall ScoreOut of 4Name(Required) First Middle Last Last 4 Digits of Social Security NumberEmail(Required) This field is hidden when viewing the formDate MM slash DD slash YYYY Proficiency Scale1 – No Experience 2 – Need Training 3 – Able to perform with supervision 4 – Able to perform independentlyWORKSETTINGGeneral OR(Required) 1 2 3 4 CVOR(Required) 1 2 3 4 Outpatient(Required) 1 2 3 4 Trauma(Required) 1 2 3 4 Peds-General OR(Required) 1 2 3 4 Peds-CVOR(Required) 1 2 3 4 First Assist(Required) 1 2 3 4 Scrub Experience(Required) 1 2 3 4 GENERAL SURGERYAbdominal Perineal Resection(Required) 1 2 3 4 Appendectomy/Cholescystectomy(Required) 1 2 3 4 Breast Biopsy(Required) 1 2 3 4 Colon Resection/Surgery(Required) 1 2 3 4 Gastrectomy(Required) 1 2 3 4 Gastric Bypass/Roux-en-Y(Required) 1 2 3 4 Hemorrhoidectomy(Required) 1 2 3 4 Herniorrhaphy - Inguinal, Ventral, Femoral, Umbilical(Required) 1 2 3 4 Laparoscopic General Surgeries(Required) 1 2 3 4 Laparoscopic Nissen Fundoplication(Required) 1 2 3 4 Mastectomy(Required) 1 2 3 4 Splenectomy(Required) 1 2 3 4 Thyroidectomy(Required) 1 2 3 4 Scrub General Surgery(Required) 1 2 3 4 CARDIOVASCULARAorta Repair(Required) 1 2 3 4 Aorto-Bifemoral/Femoral-Pop Bypass Graft(Required) 1 2 3 4 Cardiac Bypass Surgery(Required) 1 2 3 4 Carotid Endarterectomy(Required) 1 2 3 4 Endoscopic Vascular Procedures(Required) 1 2 3 4 Femoral Popliteal Bypass Graft(Required) 1 2 3 4 Laparascopic Cardiac Surgery(Required) 1 2 3 4 Robotic Assisted Cardiac Surgery(Required) 1 2 3 4 Valve Replacement/Repair(Required) 1 2 3 4 Ventricular Assist Device(Required) 1 2 3 4 Scrub CV Surgery(Required) 1 2 3 4 THORACICEndoscopic Thoracic Procedures(Required) 1 2 3 4 Esophagoogastrectomy(Required) 1 2 3 4 Mediastinotomy/Sternotomy(Required) 1 2 3 4 Thoracoscopy/Nuss Procedure(Required) 1 2 3 4 Thoracotomy(Required) 1 2 3 4 Scrub Thoracic Surgery(Required) 1 2 3 4 ORTHOPEDICTotal Joint Replacement(Required) 1 2 3 4 Closed Reduction of Fracture(Required) 1 2 3 4 External Fixator(Required) 1 2 3 4 Cannulated Hip Screws(Required) 1 2 3 4 Bankhart Procedure(Required) 1 2 3 4 Birmingham Procedure(Required) 1 2 3 4 Carpal Tunnel Release(Required) 1 2 3 4 Arthroscopy(Required) 1 2 3 4 Anterior Cruciate Ligament Reconstruction(Required) 1 2 3 4 Open Reduction Internal Fixation(Required) 1 2 3 4 Scrub Orthopedics(Required) 1 2 3 4 NEUROLOGICALCraniotomy(Required) 1 2 3 4 Steriotactic Guided Brain Biopsy(Required) 1 2 3 4 Laminectomy(Required) 1 2 3 4 Laparoscopic Anterior Laminectomy(Required) 1 2 3 4 Insertion of Vagal Nerve Stimulator(Required) 1 2 3 4 Insertion of VP Shunt(Required) 1 2 3 4 Spinal Fusion(Required) 1 2 3 4 Anterior Cervical Discectomy with Fusion(Required) 1 2 3 4 Posterior Cervical Laminectomy(Required) 1 2 3 4 Scrub Neurological Surgery(Required) 1 2 3 4 GENITOURINARYVasicaurethropexy(Required) 1 2 3 4 Marshall Marchetti(Required) 1 2 3 4 Circumcision(Required) 1 2 3 4 Cystoscopy/Cystogram/Pyelogram(Required) 1 2 3 4 Prostatectomy(Required) 1 2 3 4 Nephrectomy(Required) 1 2 3 4 Orchidectomy/Orchidopexy(Required) 1 2 3 4 Ureterostomy(Required) 1 2 3 4 Laparoscopic Assisted GU Procedures(Required) 1 2 3 4 Robotic Assisted GU Procedures(Required) 1 2 3 4 Scrub GU Surgery(Required) 1 2 3 4 GYNECOLOGICALAbdominal Hysterectomy(Required) 1 2 3 4 Anterior Posterior Repair(Required) 1 2 3 4 C-Section(Required) 1 2 3 4 D & C(Required) 1 2 3 4 Laparoscopic Assisted Hysterectomy(Required) 1 2 3 4 Laparotomy with Microtuboplasty(Required) 1 2 3 4 Robotic Assisted GYN Procedures(Required) 1 2 3 4 Vaginal Delivery(Required) 1 2 3 4 Vaginal Hysterectomy(Required) 1 2 3 4 Scrub Gyn Surgery(Required) 1 2 3 4 EAR/NOSE/THROATEndoscopic ENT Procedures(Required) 1 2 3 4 Laryngectomy(Required) 1 2 3 4 Mastoidectomy(Required) 1 2 3 4 Myringotomy with Insertion of Tubes(Required) 1 2 3 4 Radical Neck(Required) 1 2 3 4 Septoplasty(Required) 1 2 3 4 Tonsillectomy & Adenoidectomy(Required) 1 2 3 4 Tracheostomy(Required) 1 2 3 4 Tympanoplasty(Required) 1 2 3 4 Scrub ENT Surgery(Required) 1 2 3 4 Scrub ENT SurgeryCraniectomy(Required) 1 2 3 4 Craniofacial Reconstruction(Required) 1 2 3 4 Dental Surgery(Required) 1 2 3 4 Leforte 1 Maxillary/Sagittal Osteotomy(Required) 1 2 3 4 ORIF Mandibular Fracture(Required) 1 2 3 4 Otoplasty(Required) 1 2 3 4 Reconstruction of Ear(Required) 1 2 3 4 Removal of Arch Bars(Required) 1 2 3 4 Repair of Cleft Lip, Nose, Palate(Required) 1 2 3 4 Scrub Craniofacial/Oral(Required) 1 2 3 4 Rhinoplasty(Required) 1 2 3 4 PLASTICBlephoroplasty(Required) 1 2 3 4 Breast Reconstruction with Implant(Required) 1 2 3 4 Breast Reduction Mammoplasty(Required) 1 2 3 4 Face Lift(Required) 1 2 3 4 Mastectomy with Tram Flap Reconstruction(Required) 1 2 3 4 Split Thickness Skin Graft(Required) 1 2 3 4 Suction Lipectomy(Required) 1 2 3 4 Scrub Plastics(Required) 1 2 3 4 TRANSPLANTSHeart(Required) 1 2 3 4 Lung(Required) 1 2 3 4 Liver(Required) 1 2 3 4 Pancreas(Required) 1 2 3 4 Eye(Required) 1 2 3 4 Organ Donation(Required) 1 2 3 4 Scrub Transplants(Required) 1 2 3 4 OPHTHALMOLOGYCataract Extraction with Implant(Required) 1 2 3 4 Vitrectomy(Required) 1 2 3 4 Scleral Buckle(Required) 1 2 3 4 Cataract Aspiration; Anterior Vitrectomy(Required) 1 2 3 4 Corneal Transplant(Required) 1 2 3 4 Scrub Ophthalmology(Required) 1 2 3 4 GENERAL SURGERYAnal Fistulectomy/Anoplasty(Required) 1 2 3 4 Appendectomy/Cholecystectomy(Required) 1 2 3 4 Biopsy (Mass, Muscle, Lymph Node)(Required) 1 2 3 4 Bronchoscopy(Required) 1 2 3 4 Colostomy(Required) 1 2 3 4 Esophagogastroduodenoscopy w/ Biopsy(Required) 1 2 3 4 Esophagoscopy(Required) 1 2 3 4 Exploratory Laparotomy(Required) 1 2 3 4 Flexible Sigmoidoscopy(Required) 1 2 3 4 Fundoplication(Required) 1 2 3 4 Gastrostomy(Required) 1 2 3 4 Herniorrhaphy(Required) 1 2 3 4 Insertion of Port-a-Cath, Hickman, Broviac(Required) 1 2 3 4 Laparascopic General Surgery Procedures(Required) 1 2 3 4 Liver Biopsy(Required) 1 2 3 4 Percutaneous Endoscopic Gastrostomy(Required) 1 2 3 4 Thoracoscopy/Nuss Procedure(Required) 1 2 3 4 Scrub Peds General Surgery(Required) 1 2 3 4 GENITOURINARYCircumcision(Required) 1 2 3 4 Cystoscopy/Cystogram/Pyelogram(Required) 1 2 3 4 Hydrocelectomy(Required) 1 2 3 4 Nephrectomy(Required) 1 2 3 4 Orchidectomy/Orchidopexy(Required) 1 2 3 4 Repair of Hypospadias(Required) 1 2 3 4 Retrograde Pyelogram(Required) 1 2 3 4 Ureterostomy(Required) 1 2 3 4 Scrub Peds GU(Required) 1 2 3 4 NEUROCraniotomy(Required) 1 2 3 4 Insertion of Vagal Nerve Stimulator(Required) 1 2 3 4 Insertion of VP Shunt(Required) 1 2 3 4 Laminectomy(Required) 1 2 3 4 Scrub Peds Neuro(Required) 1 2 3 4 CARDIAC/VASCULARArterial Switch(Required) 1 2 3 4 ASD/VSD Repair(Required) 1 2 3 4 Atrial Septectomy(Required) 1 2 3 4 Bidirectional Glenn(Required) 1 2 3 4 BT Shunt(Required) 1 2 3 4 ECMO Insertion/Decannulation (Cardiac)(Required) 1 2 3 4 Fontan Procedure(Required) 1 2 3 4 Norwood Procedure(Required) 1 2 3 4 Pacemaker(Required) 1 2 3 4 PDA Ligation(Required) 1 2 3 4 Repair of Coarctation of Aorta(Required) 1 2 3 4 Ross Procedure(Required) 1 2 3 4 Tetralogy of Fallot Repair(Required) 1 2 3 4 Valve Repair/Replacement(Required) 1 2 3 4 Ventricular Assist Device(Required) 1 2 3 4 Scrub Peds Cardiac/Vascular(Required) 1 2 3 4 OPHTHALMOLOGYCorneal Transplant(Required) 1 2 3 4 Dacrocystorhinostomy(Required) 1 2 3 4 Excision of Chalazion(Required) 1 2 3 4 Eye Muscle Surgery(Required) 1 2 3 4 Levator Resection(Required) 1 2 3 4 Orbitotomy of Eye(Required) 1 2 3 4 Repair of Ptosis(Required) 1 2 3 4 Scrub Peds Opthalmology(Required) 1 2 3 4 Scrub Peds OpthalmologyCochlear Implant(Required) 1 2 3 4 Laryngotracheoplasty(Required) 1 2 3 4 Myringotomy with Tubes(Required) 1 2 3 4 Septoplasty(Required) 1 2 3 4 Suspension Microlaryngoscopy(Required) 1 2 3 4 Tonsillectomy & Adenoidectomy(Required) 1 2 3 4 Tracheostomy(Required) 1 2 3 4 Turbinate Reduction(Required) 1 2 3 4 Tympanoplasty/Typanomastoidectomy(Required) 1 2 3 4 Scrub Peds ENT(Required) 1 2 3 4 CRANIOFACIAL/ORAL/PLASTICSCraniectomy(Required) 1 2 3 4 Craniofacial Reconstruction(Required) 1 2 3 4 Dental Surgery(Required) 1 2 3 4 Leforte 1 Maxillary/Sagittal Osteotomy(Required) 1 2 3 4 Mandibular Osteotomy(Required) 1 2 3 4 ORIF Mandibular Fracture(Required) 1 2 3 4 Otoplasty(Required) 1 2 3 4 Reconstruction of Ear(Required) 1 2 3 4 Repair of Cleft Lip, Nose, Palate(Required) 1 2 3 4 Rhinoplasty(Required) 1 2 3 4 Skin Graft(Required) 1 2 3 4 Scrub Peds C-Fl/Oral/Plastics(Required) 1 2 3 4 ORTHOPEDICSAcetabuloplasty/Triple Innominate(Required) 1 2 3 4 Closed Reduction, Percutaneous Pin(Required) 1 2 3 4 External Fixator (Ilizarov/Orthofix)(Required) 1 2 3 4 ORIF Shoulder, Humerus, Tibia, Femur(Required) 1 2 3 4 Osteotomy/VDRD/Calcaneal/Metatarsal(Required) 1 2 3 4 Spinal Fusion/Spinal with Instrumentation(Required) 1 2 3 4 Tendoachilles Lengthening(Required) 1 2 3 4 Scrub Peds Ortho(Required) 1 2 3 4 OR EQUIPMENTElectrocautery (ESU)(Required) 1 2 3 4 Laparoscopy Systems(Required) 1 2 3 4 Neuro(Required) 1 2 3 4 OR Fracture Tables (List Types)(Required) 1 2 3 4 Orthopedic Total Joint Systems(Required) 1 2 3 4 Power Equipment(Required) 1 2 3 4 Robotics Systems(Required) 1 2 3 4 Spinal Fusion Instrumentation(Required) 1 2 3 4 (List types)PROFESSIONAL KNOWLEDGE AND SKILLSMalignant Hyperthermia Protocol(Required) 1 2 3 4 Administer and Monitor Moderate Sedation(Required) 1 2 3 4 Universal Protocol for Wrong Site Surgery(Required) 1 2 3 4 National Patient Safety Goals/Core Measures(Required) 1 2 3 4 Fall Risk Assessment/Prevention(Required) 1 2 3 4 Pressure Ulcer Risk Assessment/Prevention(Required) 1 2 3 4 Restraints/Use of Least Restrictive Device(Required) 1 2 3 4 Age Specific/Population-Based Care(Required) 1 2 3 4 Isolation Precautions(Required) 1 2 3 4 Infection Prevention(Required) 1 2 3 4 EMREpic(Required) 1 2 3 4 Cerner(Required) 1 2 3 4 Eclipsys(Required) 1 2 3 4 McKesson(Required) 1 2 3 4 Meditech(Required) 1 2 3 4 Other Computerized System(Required) 1 2 3 4 Computerized Physician Order Entry(Required) 1 2 3 4 EMR Conversion(Required) Yes No AuthorizationsBLS(Required) Yes No BLS Expiry Date:MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920NRP(Required) Yes No NRP Expiry Date:MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920PALS(Required) Yes No PALS Expiry Date:MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Certified Nurse Operating Room(Required) Yes No CNOR Expiry Date:MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Registered Nurse First Assist(Required) Yes No RNFA Expiry Date:MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Other: SpecifyOther Expiry Date:MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920AuthorizationsLegal Consent(Required) I agree to the terms and conditions.Consumer Disclosure Regarding Conducting Business Electronically, Signing Documents Electronically, and Receiving Electronic Notices and Disclosures Please read the information below, carefully, as it concerns your rights. eSignatures are an efficient way to execute an agreement with the same legal force and effect of a handwritten or “wet ink” signature. 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