Operating Room Nursing Skills Checklist
  Operating Room Nursing Skills Checklist
   NAME    
   LAST 4 OF SSN      
   DATE    
I hereby certify that ALL information I have provided on this skills checklist and all other documentation, is true and accurate. I understand and acknowledge that any misrepresentation or omission may result in disqualification from employment and/or immediate termination.  
Instructions: This checklist is meant to serve as a general guideline for our client facilities as to the level of your skills within your nursing specialty. Please use the scale below to describe your experience/expertise in each area listed below.  
Proficiency Scale: 1 = No Experience
2 = Need Training
3 = Able to perform with supervision
4 = Able to perform independently

 
       
Rating Stars (Click) WORKSETTING 1 2 3 4  
General OR  
CVOR  
Outpatient  
Trauma  
Peds-General OR  
Peds-CVOR  
First Assist  
Scrub Experience  
Rating Stars (Click) GENERAL SURGERY 1 2 3 4  
Abdominal Perineal Resection  
Appendectomy/Cholescystectomy  
Breast Biopsy  
Colon Resection/Surgery  
Gastrectomy  
Gastric Bypass/Roux-en-Y  
Hemorrhoidectomy  
Herniorrhaphy - Inguinal, Ventral, Femoral, Umbilical  
Laparoscopic General Surgeries  
Laparoscopic Nissen Fundoplication  
Mastectomy  
Splenectomy  
Thyroidectomy  
Scrub General Surgery  
Rating Stars (Click) CARDIOVASCULAR 1 2 3 4  
Aorta Repair  
Aorto-Bifemoral/Femoral-Pop Bypass Graft  
Cardiac Bypass Surgery  
Carotid Endarterectomy  
Endoscopic Vascular Procedures  
Femoral Popliteal Bypass Graft  
Laparascopic Cardiac Surgery  
Robotic Assisted Cardiac Surgery  
Valve Replacement/Repair  
Ventricular Assist Device  
Scrub CV Surgery  
Rating Stars (Click) THORACIC 1 2 3 4  
Endoscopic Thoracic Procedures  
Esophagoogastrectomy  
Mediastinotomy/Sternotomy  
Thoracoscopy/Nuss Procedure  
Thoracotomy  
Scrub Thoracic Surgery  
Rating Stars (Click) ORTHOPEDIC 1 2 3 4  
Total Joint Replacement  
Closed Reduction of Fracture  
External Fixator  
Cannulated Hip Screws  
Bankhart Procedure  
Birmingham Procedure  
Carpal Tunnel Release  
Arthroscopy  
Anterior Cruciate Ligament Reconstruction  
Open Reduction Internal Fixation  
Scrub Orthopedics  
Rating Stars (Click) NEUROLOGICAL 1 2 3 4  
Craniotomy  
Steriotactic Guided Brain Biopsy  
Laminectomy  
Laparoscopic Anterior Laminectomy  
Insertion of Vagal Nerve Stimulator  
Insertion of VP Shunt  
Spinal Fusion  
Anterior Cervical Discectomy with Fusion  
Posterior Cervical Laminectomy  
Scrub Neurological Surgery  
Rating Stars (Click) GENITOURINARY 1 2 3 4  
Vasicaurethropexy  
Marshall Marchetti  
Circumcision  
Cystoscopy/Cystogram/Pyelogram  
Prostatectomy  
Nephrectomy  
Orchidectomy/Orchidopexy  
Ureterostomy  
Laparoscopic Assisted GU Procedures  
Robotic Assisted GU Procedures  
Scrub GU Surgery  
Rating Stars (Click) GYNECOLOGICAL 1 2 3 4  
Abdominal Hysterectomy  
Anterior Posterior Repair  
C-Section  
D & C  
Laparoscopic Assisted Hysterectomy  
Laparotomy with Microtuboplasty  
Robotic Assisted GYN Procedures  
Vaginal Delivery  
Vaginal Hysterectomy  
Scrub Gyn Surgery  
Rating Stars (Click) EAR/NOSE/THROAT 1 2 3 4  
Endoscopic ENT Procedures  
Laryngectomy  
Mastoidectomy  
Myringotomy with Insertion of Tubes  
Radical Neck  
Septoplasty  
Tonsillectomy & Adenoidectomy  
Tracheostomy  
Tympanoplasty  
Scrub ENT Surgery  
Rating Stars (Click) CRANIOFACIAL/ORAL 1 2 3 4  
Craniectomy  
Craniofacial Reconstruction  
Dental Surgery  
Leforte 1 Maxillary/Sagittal Osteotomy  
ORIF Mandibular Fracture  
Otoplasty  
Reconstruction of Ear  
Removal of Arch Bars  
Repair of Cleft Lip, Nose, Palate  
Rhinoplasty  
Scrub Craniofacial/Oral  
Rating Stars (Click) PLASTIC 1 2 3 4  
Blephoroplasty  
Breast Reconstruction with Implant  
Breast Reduction Mammoplasty  
Face Lift  
Mastectomy with Tram Flap Reconstruction  
Split Thickness Skin Graft  
Suction Lipectomy  
Scrub Plastics  
Rating Stars (Click) TRANSPLANTS 1 2 3 4  
Heart  
Lung  
Liver  
Pancreas  
Eye  
Organ Donation  
Scrub Transplants  
Rating Stars (Click) OPHTHALMOLOGY 1 2 3 4  
Cataract Extraction with Implant  
Vitrectomy  
Scleral Buckle  
Cataract Aspiration; Anterior Vitrectomy  
Corneal Transplant  
Scrub Ophthalmology  
  PEDIATRICS    
Rating Stars (Click) GENERAL SURGERY 1 2 3 4  
Anal Fistulectomy/Anoplasty  
Appendectomy/Cholecystectomy  
Biopsy (Mass, Muscle, Lymph Node)  
Bronchoscopy  
Colostomy  
Esophagogastroduodenoscopy w/ Biopsy  
Esophagoscopy  
Exploratory Laparotomy  
Flexible Sigmoidoscopy  
Fundoplication  
Gastrostomy  
Herniorrhaphy  
Insertion of Port-a-Cath, Hickman, Broviac  
Laparascopic General Surgery Procedures  
Liver Biopsy  
Percutaneous Endoscopic Gastrostomy  
Thoracoscopy/Nuss Procedure  
Scrub Peds General Surgery  
Rating Stars (Click) GENITOURINARY 1 2 3 4  
Circumcision  
Cystoscopy/Cystogram/Pyelogram  
Hydrocelectomy  
Nephrectomy  
Orchidectomy/Orchidopexy  
Repair of Hypospadias  
Retrograde Pyelogram  
Ureterostomy  
Scrub Peds GU  
Rating Stars (Click) NEURO 1 2 3 4  
Craniotomy  
Insertion of Vagal Nerve Stimulator  
Insertion of VP Shunt  
Laminectomy  
Scrub Peds Neuro  
Rating Stars (Click) CARDIAC/VASCULAR 1 2 3 4  
Arterial Switch  
ASD/VSD Repair  
Atrial Septectomy  
Bidirectional Glenn  
BT Shunt  
ECMO Insertion/Decannulation (Cardiac)  
Fontan Procedure  
Norwood Procedure  
Pacemaker  
PDA Ligation  
Repair of Coarctation of Aorta  
Ross Procedure  
Tetralogy of Fallot Repair  
Valve Repair/Replacement  
Ventricular Assist Device  
Scrub Peds Cardiac/Vascular  
Rating Stars (Click) TRANSPLANT 1 2 3 4  
Heart  
Kidney  
Liver/Pancreas  
Lung  
Organ Donation  
Scrub Peds Transplant  
Rating Stars (Click) OPHTHALMOLOGY 1 2 3 4  
Corneal Transplant  
Dacrocystorhinostomy  
Excision of Chalazion  
Eye Muscle Surgery  
Levator Resection  
Orbitotomy of Eye  
Repair of Ptosis  
Scrub Peds Opthalmology  
Rating Stars (Click) EAR/NOSE/THROAT 1 2 3 4  
Cochlear Implant  
Laryngotracheoplasty  
Myringotomy with Tubes  
Septoplasty  
Suspension Microlaryngoscopy  
Tonsillectomy & Adenoidectomy  
Tracheostomy  
Turbinate Reduction  
Tympanoplasty/Typanomastoidectomy  
Scrub Peds ENT  
Rating Stars (Click) CRANIOFACIAL/ORAL/PLASTICS 1 2 3 4  
Craniectomy  
Craniofacial Reconstruction  
Dental Surgery  
Leforte 1 Maxillary/Sagittal Osteotomy  
Mandibular Osteotomy  
ORIF Mandibular Fracture  
Otoplasty  
Reconstruction of Ear  
Repair of Cleft Lip, Nose, Palate  
Rhinoplasty  
Skin Graft  
Scrub Peds C-Fl/Oral/Plastics  
Rating Stars (Click) ORTHOPEDICS 1 2 3 4  
Acetabuloplasty/Triple Innominate  
Arthroscopy of Knee, Wrist, Shoulder  
Closed Reduction, Percutaneous Pin  
External Fixator (Ilizarov/Orthofix)  
ORIF Shoulder, Humerus, Tibia, Femur  
Osteotomy/VDRD/Calcaneal/Metatarsal  
Spinal Fusion/Spinal with Instrumentation  
Tendoachilles Lengthening  
Scrub Peds Ortho  
Rating Stars (Click) OR EQUIPMENT 1 2 3 4  
Electrocautery (ESU)  
Laparoscopy Systems  
Neuro  
OR Fracture Tables (List Types)  
Orthopedic Total Joint Systems  
Power Equipment  
Robotics Systems (List types)  
Spinal Fusion Instrumentation  
Rating Stars (Click) PROFESSIONAL KNOWLEDGE AND SKILLS 1 2 3 4  
Malignant Hyperthermia Protocol  
Administer and Monitor Moderate Sedation  
Universal Protocol for Wrong Site Surgery  
National Patient Safety Goals/Core Measures  
Fall Risk Assessment/Prevention  
Pressure Ulcer Risk Assessment/Prevention  
Restraints/Use of Least Restrictive Device  
Age Specific/Population-Based Care  
Isolation Precautions  
Infection Prevention  
Rating Stars (Click) EMR 1 2 3 4  
Epic  
Cerner  
Eclipsys  
McKesson  
Meditech  
Other Computerized System  
Computerized Physician Order Entry  
  EMR Conversion
   
CERTIFICATIONS   Expiry Date :  
BLS  
NRP  
PALS  
Certified Nurse Operating Room  
Registered Nurse First Assist  
  Other: Specify