OR Surgical 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 independentlyGENERAL 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 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 THORACICEndoscopic Thoracic Procedures(Required) 1 2 3 4 Esophagogastrectomy(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 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 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 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 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 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 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 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 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 TRANSPLANTSHeart(Required) 1 2 3 4 Lung(Required) 1 2 3 4 Liver(Required) 1 2 3 4 Pancreas(Required) 1 2 3 4 Organ Donation(Required) 1 2 3 4 OPHTHAMOLOGYCataract 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 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 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 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 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(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 TRANSPLANTHeart(Required) 1 2 3 4 Kidney(Required) 1 2 3 4 Liver/Pancreas(Required) 1 2 3 4 Lung(Required) 1 2 3 4 Organ Donation(Required) 1 2 3 4 OPHTHAMOLOGYCorneal 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 EAR/NOSE/THROATCochlear 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 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 ORTHOPEDICSAcetabuloplasty/Triple Innominate(Required) 1 2 3 4 Arthroscopy of Knee, Wrist, Shoulder(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 OR EQUIPMENTElectrocautery (ESU)(Required) 1 2 3 4 Laparoscopy Systems(Required) 1 2 3 4 Neuro(Required) 1 2 3 4 OR Fracture Tables(Required) 1 2 3 4 List types hereOrthopedic Total Joint Systems(Required) 1 2 3 4 Power Equipment(Required) 1 2 3 4 Robotics Systems(Required) 1 2 3 4 List TypesSpinal Fusion Instrumentation(Required) 1 2 3 4 PROFESSIONAL KNOWLEDGE AND SKILLSMalignant Hyperthermia Protocol(Required) 1 2 3 4 Infection Prevention(Required) 1 2 3 4 Isolation Precautions(Required) 1 2 3 4 National Patient Safety Goals/Core Measures(Required) 1 2 3 4 Universal Protocol(Required) 1 2 3 4 EMREpic(Required) 1 2 3 4 Picis(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 CERTIFICATIONSBLS(Required) Yes No BLS Expiry Date MM slash DD slash YYYY CST(Required) Yes No CST Expiry Date MM slash DD slash YYYY CSPT(Required) Yes No CSPT Expiry Date MM slash DD slash YYYY Other: SpecifyOther Expiry Date MM slash DD slash YYYY Age Specific CompetenciesInfant (Birth - 1 year)(Required) 1 2 3 4 Preschooler (ages 2-5 years)(Required) 1 2 3 4 Childhood (ages 6-12 years)(Required) 1 2 3 4 Adolescents (ages 13-21 years)(Required) 1 2 3 4 Young Adults (ages 22-39 years)(Required) 1 2 3 4 Adults (ages 40-64 years)(Required) 1 2 3 4 Older Adults (ages 65-79 years)(Required) 1 2 3 4 Elderly (ages 80+ years)(Required) 1 2 3 4 AuthorizationsLegal 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 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