Operating Room RN Skills Checklist

Please rate your experience / frequency within the last year

0 = No Experience / Observed Only
1 = Limited Experience / Rarely Done (<6 times/year)
2 = May Need Some Review / Occasionally Done (1 – 2 times/month)
3 = Experienced / Frequently Done (daily or weekly)

Full Name(Required)

Email(Required)

Send to(Required)

Date(Required)

AGE OF CLIENTS:

Newborn/Neonate (birth to 30 days)(Required)

Infant (31 days to 12 months)(Required)

Toddler/Preschool (13 months to 5 years)(Required)

School Age Child/adolescent (6 years to 18 years)(Required)

Young Adults Middle Adult (19 years to 64 years)(Required)

Older Adults/Elderly (65+years)(Required)

GENERAL SURGERY

Scrub(Required)

Circulate(Required)

First Assist(Required)

Abdominal Perineal Resection(Required)

Adrenalectomy(Required)

Bowel Resection(Required)

Cholecystectomy(Required)

Colostomy/Ileostomy(Required)

Gastrectomy(Required)

Hemicolectomy(Required)

Hepatic Resection(Required)

Herniorrhaphy-Femoral/Inguinal(Required)

Hiatal Herniorrhaphy-Transabdominal(Required)

Pancreatectomy(Required)

Organ Procurement(Required)

Radical Mastectomy(Required)

Saphenous Vein Ligation and Stripping(Required)

Splenectomy(Required)

Thyroidectomy(Required)

Tracheostomy(Required)

Whipple Procedure(Required)

LAPAROSCOPIC PROCEDURES

Scrub(Required)

Circulate(Required)

First Assist(Required)

Hysterectomy(Required)

Cholecystectomy(Required)

Appendectomy(Required)

Hernia Repair(Required)

Colon Resection(Required)

GYNECOLOGY

Scrub(Required)

Circulate(Required)

First Assist(Required)

Caesarean Section(Required)

Dilation & Curettage(Required)

Hysterectomy-Vaginal(Required)

Hysterectomy-Abdominal(Required)

Laser Surgery(Required)

Radium Insertion(Required)

Salpingo-Opherectomy(Required)

Shirodkar Procedures(Required)

Termination of Pregnancy(Required)

Tubal Ligation(Required)

Vaginectomy(Required)

Vaginal Reconstruction(Required)

G.U. & CYSTO

Scrub(Required)

Circulate(Required)

First Assist(Required)

Circumcision(Required)

Cystoscopy/Cystostomy(Required)

Cystectomy(Required)

Hypospadias Repair(Required)

Ileal Loop(Required)

Lithotripsy(Required)

Nephrectomy(Required)

Penile Implant(Required)

Prostatectomy(Required)

Ureterolithotomy(Required)

T.U.R.P./T.U.R.B.(Required)

Vasectomy(Required)

ORTHOPEDIC

Amputation – Leg or Arm(Required)

Application of Halo Traction(Required)

Arthroscopy/Arthrotomy(Required)

Closed Pinning & Reduction of Extremities(Required)

External Compression Devices(Required)

Insertion of Finger Prosthesis(Required)

Total Joint Replacement – Knee, Hip, Shoulder(Required)

Spinal Fusion – Harrington Rods(Required)

Spica Cast Application(Required)

O.R.I.F. – Shoulder, Hip, Humerus, Etc.(Required)

Repair of Dislocation(Required)

Patellectomy(Required)

Tendon Implants & Reanastomosis(Required)

NEUROSURGERY

Scrub(Required)

Circulate(Required)

First Assist(Required)

Anterior Cervical Fusion(Required)

Burrholes for Subdural Hematoma(Required)

Craniotomy(Required)

Laminectomy(Required)

Meningocele Repair(Required)

Shunt Procedures – VP/VA(Required)

PLASTICS

Scrub(Required)

Circulate(Required)

First Assist(Required)

Face Lift(Required)

Skin Grafting(Required)

Abdominoplasty/Abdominal Lipectomy(Required)

Augmentation Mammoplasty(Required)

Cleft Lip/Palate Repair(Required)

Dermabrasion(Required)

Digital Flexor Tendon Repair(Required)

Liposuction(Required)

Myelomeningocele Repair(Required)

Otoplasty(Required)

Rhinoplasty(Required)

Reduction of Facial Fracture(Required)

GENERAL SKILLS

Scrub(Required)

Circulate(Required)

First Assist(Required)

Excision of Chalazion(Required)

Correction of Ectropion/Entropion(Required)

Corneal Transplant(Required)

Enucleation(Required)

I.O.I. Implants(Required)

Lacrimal Duct Probing(Required)

Refractive Keratoplasty(Required)

Repair of Retinal Detachment(Required)

Vitrectomy(Required)

EAR, NOSE & THROAT

Scrub(Required)

Circulate(Required)

First Assist(Required)

Caldwell-Luc(Required)

Ethmoidectomy(Required)

Frontal Flap Sinus Procedure(Required)

Laryngectomy(Required)

Open Reduction Facial Fractures(Required)

Radical Neck(Required)

Tonsillectomy & Adenoidectomy(Required)

Myringotomy(Required)

Mastoidectomy(Required)

Tympanoplasty(Required)

Stapedectomy(Required)

Nasal Polypectomy(Required)

Laryngoscopy(Required)

THORACIC

Scrub(Required)

Circulate(Required)

First Assist(Required)

Chest Tube Set-Up(Required)

Hiatal Hernia(Required)

Pneumonectomy/ Lobectomy(Required)

Sternal Splitting(Required)

Thoracotomy(Required)

Bronchoscopy(Required)

Lung/Wedge Resection(Required)

ENDOSCOPY

Scrub(Required)

Circulate(Required)

First Assist(Required)

Bronchoscopy(Required)

Cystoscopy(Required)

Gastroscopy ☐0 ☐1 ☐2 ☐3(Required)

Colonoscopy(Required)

CARDIOVASCULAR

Scrub(Required)

Circulate(Required)

First Assist(Required)

A-V Shunts(Required)

Aortic Aneurysm, Abdominal(Required)

Aorto-Femoral Bypass(Required)

Graft Insertion(Required)

Cardiac Valve Replacement(Required)

Coronary Artery Bypass Graft-on Pump(Required)

Endarterectomy, Carotid/Femoral(Required)

Femoral-Popliteal Bypass(Required)

External Temporary Pacemaker(Required)

Internal Pacemaker Insertion(Required)

Intra-Aortic Balloon Pump Catheter(Required)

Patent Ductus Repair(Required)

Pericardial Windows(Required)

Repair of Septal Defects(Required)

Thrombectomy(Required)

Vena Cava Ligation(Required)

TRANSPLANTS

Scrub(Required)

Circulate(Required)

First Assist(Required)

Bone(Required)

Bone Marrow(Required)

Corneal(Required)

Harvesting(Required)

Heart(Required)

Kidney(Required)

Liver(Required)

Lung(Required)

Multi-Organ(Required)

Pancreas(Required)

Skin(Required)

EQUIPMENT

Argon Beam Coagulators(Required)

Bair Hugger(Required)

Blood / Fluid Warmer(Required)

Cell Saver(Required)

Computer Navigation System(Required)

Cry-Ophthalmic Unit(Required)

Disposable Grounding Pads(Required)

Electrosurgical Unit(Required)

Emerson Thoracic Pump(Required)

Ethylene Oxide Sterilizer – AMSCO(Required)

Eye Magnet(Required)

Fiber Optic Illuminator(Required)

Flash Autoclave – AMSCO(Required)

Hypo / Hyperthermia Unit(Required)

Lights(Required)

Mesh Graft(Required)

Microscopes(Required)

Nerve Stimulator(Required)

Nitrous Oxide Bank(Required)

Orthopedic Arm Board With Drain(Required)

Oxygen(Required)

Pleurevac Disposable Chest Drainage(Required)

Pneumatic Tourniquet(Required)

Retractors(Required)

Scalpels(Required)

Staples(Required)

Sterad Machine(Required)

Steris Unit(Required)

Steri-Vac Aeration Cabinet, 3M, Portable(Required)

Sternal Saw(Required)

Suction Machines(Required)

Surgical Drapes(Required)

Sutures(Required)

Tele-Thermometer(Required)

Tourniquet(Required)

Vac-Pac Positioner(Required)

Vacuum Curettage(Required)

STERILIZATION OF EQUIPMENT

Log(Required)

Biological Indicators(Required)

Autoclave Operations(Required)

High Level(Required)

STERIS(Required)

Steam(Required)

Gas(Required)

Flash(Required)

ANESTHESIA

Assist With Intubation(Required)

Conscious Sedation(Required)

Management of Malignant Hyperthermia Crisis(Required)

PHLEBOTOMY / IV THERAPY

Equipment and Procedures(Required)

Administration of Blood / Products(Required)

Packed Red Blood Cells(Required)

Whole Blood(Required)

Assist With IA / IV Therapy(Required)

Insert A-Lines(Required)

Insert CVP-Jugular / Subclavian(Required)

Insert Blood Central Line(Required)

Drawing Venous Blood(Required)

Starting IV – Angiocath(Required)

BACKGROUND EXPERIENCE

Small Hospital(Required)

Large Hospital(Required)

Outpatient(Required)

Acute Care / Hospital(Required)

Cancer Center(Required)

Clinic(Required)

Managed Care(Required)

SNF / Long Term Care(Required)

Home Health(Required)

OTHER SKILLS

List here(Required)

Please rate your experience / frequency within the last year

AGE OF CLIENTS:

GENERAL SURGERY

LAPAROSCOPIC PROCEDURES

GYNECOLOGY

G.U. & CYSTO

ORTHOPEDIC

NEUROSURGERY

PLASTICS

GENERAL SKILLS

EAR, NOSE & THROAT

THORACIC

ENDOSCOPY

CARDIOVASCULAR

TRANSPLANTS

EQUIPMENT

STERILIZATION OF EQUIPMENT

ANESTHESIA

PHLEBOTOMY / IV THERAPY

BACKGROUND EXPERIENCE

OTHER SKILLS

.

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