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Operating Room Skills Checklist
First name:
Last name:
Phone:
Email:
SSN (last 4 only):
Date: (MM/DD/YYYY)
Key - for each box mark:
Limited or no experience
Somewhat experienced but may need review
Can function independently
Competent to supervise
Circulate
Scrub
Assist
1
2
3
4
1
2
3
4
1
2
3
4
Procedures
Cardiovascular
Aorto-Femoral Bypass, Graft Insertion
A-V Shunts
Aneurysms with Graft Replacement
Cardiac Valve Replacement
Coronary Artery Bypass Graft
Endarterectomy - Carotid/Femoral
External Temporary Pacemaker
Groshong/Hickman Vascular Catheter
Internal Pacemaker Insertion
Intra-Aortic Balloon Pump Catheter
Saphenous Vein Ligation and Stripping
Thrombectomy
Dental/Oral-Facial
Arch Bars
Closed Reduction Facial Fractures/Wiring
Fractured Jaw, Mandibular and Zagomatic
Mandibular Osteotomy
Maxillary Procedure with Graft
TMJ with Arthoplasty
Endoscopy
Bronchoscopy
Colonoscopy
Cytoscopy
Gastroscopy
Laryngoscope
Sigmoidoscopy
Thoracoscopy
Ear/Nose/Throat
Antral Windows
Closed Reduction Facial/Nasal Fx
Ethmoidectomy
Ear/Nose/Throat continued
Laryngectomy
Mandibulectomy
Mastoidectomy
Nasal Polypectomy
Open Reduction Facial/Nasal Fx
Radical Neck Dissection
Septoplasty/Rhinoplasty
Tracheostomy
Tympanoplasty
Eye
Cataract Extraction
Corneal Transplant
Enucleation
Fenestration Procedure
Lacrimal Duct Probing
Orbital Implant
Repair of Retinal Detachment
General
Abdominal Perineal Resection
Bowel Resection
Cholecystectomy
Colostomy/Ileostomy
Gastrectomy
Herniorrhaphy-Feneral/Inguinal
Hiatal Herniorrhaphy Transabdominal
Pilonidal Cystectomy
Organ Procurement
Radical Mastectomy
Sentinel Node Biopsy
Splenectomy
Thyroidectomy
Tracheostomy
Genitourinary/Cystoscopy
Cystoscopy/Cystostomy
Lithotripsy
Nephrectomy
Penile Implant
Prostatectomy
TURP/TURB
Ureterolithotomy
Vasectomy
Gynecology
Caesarean Section
Dilation and Curettage
Hysterectomy - Abdominal
Hysterectomy - Vaginal
Ovarian Cystectomy
Radium Implant
Salpingo-Oophorectomy
Suction Curettage
Termination of Pregnancy
Tubal Ligation
Vaginal Reconstruction
Laparoscopy
Appendectomy
Cholecystectomy/Cholangiogram
Colon Resection
Hernia Repair
Salpingo-Oophorectomy
Tubal Ligation
Vaginal Hysterectomy
Neurology
Cervical Fusion
Lumbar Interbody Fusion
Burr Holes for Subdural Hematoma
Carotid Ligation
Craniotoplasty/Craniotomy
Discectomy
Insertion Nerve Stimulators/Medication Pumps
Shunts
Lumbar Peritoneal
Ventricular Atrial
Ventricular Peritoneal
Orthopedics
Acetabular/Pelvic ORIF
Amputation
Anterior Cruciate Ligament Repair
Application of External Fixators
Application of Halo Traction
Arthroscopy/Arthrotomy
Bunionectomy
Bursa
Carpal Tunnel Release
Closed Reduction Fracture
Hand Surgery
Iliac Crest Bone Graft
Hip Protheses
Intramedullary Rods
Laminectomy
Open Reduction of Fracture
Rotator Cuff Repair
Reduction with Compression Set
Reimplantation of Digits
Sacro-iliac Joint Screws
Spica Cast Application
Spinal Fusion
Tendon Transplants
Total Joint Replacements/Revisions
Pediatric
Patent Ductus
Repair of Septal Defects
Coarctation of Aorta
Tetralogy of Fallot
Pacemaker
Cleft Lip/Palate Repair
Myringotomy with Tubes
Tonsillectomy/Adenoidectomy
Hypospadias Repair
Omphalocele Repair
Pyloric Stenosis
Myelomeningocele Repair
A-V Malformation
Harrington Rod Instrumentation/Dwyer Procedure
Resection of Coarctation Aorta
Plastics
Abdominal Lipectomy/Abdominoplasty
Face Lift
Mammoplasty
Otoplasty
Rhinoplasty
Scar Revisions
Skin Grafts
Suction Lipectomy
Thoracic
Rib Excision
Closed Thoracotomy
Esophagectomy
Rib Resection
Thoracoplasty
Tracheal Resection
Transthoracic Diaphragmatic Herniorrhaphy
Transplant
Bone
Bone Marrow
Corneal
Heart
Kidney
Liver
Lung
Multi-Organ
Pancreas
Skin
Trauma
Burns
Gunshot/Stab Wounds
Motor Vehicle Accidents
Traumatic Amputations
Equipment
Anspach Instruments
Aquamatic K Thermia Unit
Argon Beam Coagulator
Blood Warmer
Bovie Electrosurgical Unit
Cardiac Monitor and Pacemaker
Cell Saver
Dermatones
Disposable Bovie Plates
Drills
Dual Tract Lights
Ethylene Oxide Sterilizer
Fiber Optic Luminators
Flash Autoclave
Fracture Table
Pneumatic Tourniquet
Resuscitator