RN Experience and Skill Checklist

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Name:

Date:

RN Experience and Skill Checklist

Operating Room (Circulating and Scrub)

Instructions: In the following sections, we ask you to rate yourself on your skill and experience/comfort level for specific nursing/medical procedures, medications, etc. that are specific for OR RN’s. The rating system is as follows:

0=No experience

1=Minimal experience; review and/or supervision required

2=Experienced; able to perform without supervision

3=Extensive experience; can assist others; well skilled

Indicate here is your experience is primarily circulating or scrubbing or both. (circle)

If your experience is with both circulating and scrubbing the write S or a C or both in the box where you feel your rate yourself with your comfort and familiarity with the following surgeries…

CARDIOVASCULAR SURGERY

0 / 1 / 2 / 3
Cardiac Bypass on Pump
Cardiac Bypass off Pump
Valve Replacement/Repair
Ascending/Descending Aneurysm Repair
LV Resection
Laser Revascularization

TRANSPLANT PROCEDURES

0 / 1 / 2 / 3
Eye
Heart
Kidney
Liver
Lung
Organ Donation

THORACIC SURGERY

0 / 1 / 2 / 3
Bronchoscopy
Thorascopy
Mediastinoscopy
Mediastinotomy
Esophogastrectomy
Sternotomy
1st Rib Resection
Sternal Resection

VASCULAR SURGERY

0 / 1 / 2 / 3
Aorto-Bifemoral Bypass Graft
Femoral Popliteal Bypass Graft
Carotid Endartectomy
Arterio-Venous Bypass Graft
Vein Ligation/Stripping
Insertion of Permanent Pacemaker
Insertion of Internal Defibrillator

NEUROSURGERY

0 / 1 / 2 / 3
Craniotomy
Steriotactic Guided Brain Biopsy
Laminectomy
Laparoscopic Anterior Laminectomy
Spinal Fusion
Anterior Cervical Discectomy with Fusion
Posterior Cervical Laminectomy

GENERAL SURGERY

0 / 1 / 2 / 3
Anal Fistulectomy/Anoplasty
Appendectomy
Biopsy (Mass, Muscle, Lymph Node)
Bronchoscopy
Cholecystectomy
Colonscopy
Colonstomy
Esophagogastroduodenoscopy with Biopsy
Esophagoscopy
Excision of Mass
Exploratory Laparotomy
Flexible Sigmoidoscopy
Fundoplication
Gastrostomy
Herniorraphy

GU SURGERY

0 / 1 / 2 / 3
Vasicaurethropexy
Marshall Marchetti
Circumcision
Hydrocelectomy, Varicelectomy
Ochiectomy
Radical Prostatectomy
Suprapubic, Retropubic Prostatectomy
Nephrectomy
Ureterolithotomy
Cystectomy
Percutaneous Nephrolithotomy

ORTHOPEDIC SURGERY

0 / 1 / 2 / 3
Closed Reduction of Fracture
External Fixator
DHS Hip
Bipolar Hip Prosthesis
Cannulated Hip Screws
Bankhart Procedure
Carpal Tunnel Release
Achilles Tendon Repair
Intramedullary Rodding
Arthroscopic Knee
Arthroscopic Anterior Cruciate Ligament Reconstruction
Arthroscopic Shoulder
Arthroscopic Ankle
Arthroscopic Foot Surgery
Open Reduction Internal Fixation~Large Bone
Open Reduction Internal Fixation~Small Bone

ENT SURGERY

0 / 1 / 2 / 3
Tonsillectomy & Adenoidectomy
Myringotomy with Insertion of Tubes
Laryngoscopy
Microlaryngoscopy
Pandoscopy
Tympanoplasty
Mastoid
Septoplasty
Sinus Endoscopy
Turbinectomy
Radical Neck
Laryngectomoy

EYE SURGERY

0 / 1 / 2 / 3
Cataract Extraction with Implant
Vitrectomy
Scleral Buckle

PLASTICS

0 / 1 / 2 / 3
Split Thickness Skin Graft
Breast Reduction Mammoplasty
Breast Reconstruction with Implant
(Other…specify)

FAMILIARITY WITH STERILATION

0 / 1 / 2 / 3
Flash Autoclaves
Steam Sterilization
EO (Gas) Sterilization
Hydrogen Peroxide (STERIS)
High Level Disinfection (Gluteraldehyde)
Rapid Readout
Biological Indicators

FAMILIARITY WITH SPECIFIC OR EQUIPMENT

0 / 1 / 2 / 3
OR Fracture Tables…List types…
Electrocautery (ESU)
…Valley Lab
…ConMed
…Harmonic Scapel
…Other
Laparoscopy Systems…Specify…
Power Equipment
…Stryker
…3M
…Hall
…Other (Specify)…
Orthopedic Total Joint Systems…Specify…
Neuro
…CUSA
…Midas Rex
…Other (Specify)…
Spinal Fusion Instrumentation…Specify…
Computerized Charting…Specify

My experience is primarily in the following settings:

Years / Specialty
Endoscopy
ENT
Eye
General
GYN
GU
Neuro
Opthalmology
Oral
Ortho
Plastics
Thoracic/Open Heart
Transplant
Trauma
Urology
Vascular
Adult
Peds

OTHER SKILLS/PROCEDURES/SPECIAL TRAINING/CEU SEMINARS:

EXPERIENCE:

Total number of years as a RN Total number of years as a LVN

Please indicate the number of years of experience for the following areas of expertise:

Administration
Supervision
Teaching
Emergency Department
Urgent Care
ER Observation Area
Trauma
ICU
SICU
MICU
PICU
NICU
CCU
DOU
Telemetry
Medical Floor
Surgical Floor
Recovery Room
Operating Room
Circulating Nurse OR
Open Heart Operating Room
Neurology
Chemical Dependency
Geriatrics
Psychiatic
Oncology
Orthopedics
Critical Care Transport RN
MICN
Rehabilitation
Pediatrics
Labor and Delivery
Mother/Baby/Post-partum
Home Health / Public Health
Research / Medical Sales
Clinic/Urgent Care
Nurses Aide/Tech
Paramedic / EMT
Other (specify)

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