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Operating Room Surgical Technologist 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 |
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| Rating Stars (Click) | GENERAL SURGERY | 1 | 2 | 3 | 4 | ||
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Abdominal Perineal Resection | ||||||
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Appendectomy/Cholescystectomy | ||||||
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Breast Biopsy | ||||||
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Colon Resection/Surgery | ||||||
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Gastrectomy | ||||||
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Gastric Bypass/Roux-en-Y | ||||||
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Hemorrhoidectomy | ||||||
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Herniorrhaphy - Inguinal, Ventral, Femoral, Umbilical | ||||||
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Laparoscopic General Surgeries | ||||||
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Laparoscopic Nissen Fundoplication | ||||||
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Mastectomy | ||||||
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Splenectomy | ||||||
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Thyroidectomy | ||||||
| Rating Stars (Click) | CARDIOVASCULAR | 1 | 2 | 3 | 4 | ||
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Aorta Repair | ||||||
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Aorto-Bifemoral/Femoral-Pop Bypass Graft | ||||||
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Cardiac Bypass Surgery | ||||||
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Carotid Endarterectomy | ||||||
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Endoscopic Vascular Procedures | ||||||
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Femoral Popliteal Bypass Graft | ||||||
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Laparascopic Cardiac Surgery | ||||||
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Robotic Assisted Cardiac Surgery | ||||||
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Valve Replacement/Repair | ||||||
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Ventricular Assist Device | ||||||
| Rating Stars (Click) | THORACIC | 1 | 2 | 3 | 4 | ||
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Endoscopic Thoracic Procedures | ||||||
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Esophagogastrectomy | ||||||
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Mediastinotomy/Sternotomy | ||||||
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Thoracoscopy/Nuss Procedure | ||||||
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Thoracotomy | ||||||
| Rating Stars (Click) | ORTHOPEDIC | 1 | 2 | 3 | 4 | ||
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Total Joint Replacement | ||||||
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Closed Reduction of Fracture | ||||||
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External Fixator | ||||||
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Cannulated Hip Screws | ||||||
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Bankhart Procedure | ||||||
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Birmingham Procedure | ||||||
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Carpal Tunnel Release | ||||||
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Arthroscopy | ||||||
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Anterior Cruciate Ligament Reconstruction | ||||||
| Rating Stars (Click) | NEUROLOGICAL | 1 | 2 | 3 | 4 | ||
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Craniotomy | ||||||
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Steriotactic Guided Brain Biopsy | ||||||
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Laminectomy | ||||||
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Laparoscopic Anterior Laminectomy | ||||||
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Insertion of Vagal Nerve Stimulator | ||||||
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Insertion of VP Shunt | ||||||
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Spinal Fusion | ||||||
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Anterior Cervical Discectomy with Fusion | ||||||
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Posterior Cervical Laminectomy | ||||||
| Rating Stars (Click) | GENITOURINARY | 1 | 2 | 3 | 4 | ||
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Vasicaurethropexy | ||||||
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Marshall Marchetti | ||||||
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Circumcision | ||||||
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Cystoscopy/Cystogram/Pyelogram | ||||||
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Prostatectomy | ||||||
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Nephrectomy | ||||||
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Orchidectomy/Orchidopexy | ||||||
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Ureterostomy | ||||||
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Laparoscopic Assisted GU Procedures | ||||||
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Robotic Assisted GU Procedures | ||||||
| Rating Stars (Click) | GYNECOLOGICAL | 1 | 2 | 3 | 4 | ||
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Abdominal Hysterectomy | ||||||
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Anterior Posterior Repair | ||||||
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C-Section | ||||||
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D & C | ||||||
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Laparoscopic Assisted Hysterectomy | ||||||
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Laparotomy with Microtuboplasty | ||||||
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Robotic Assisted GYN Procedures | ||||||
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Vaginal Delivery | ||||||
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Vaginal Hysterectomy | ||||||
| Rating Stars (Click) | EAR/NOSE/THROAT | 1 | 2 | 3 | 4 | ||
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Endoscopic ENT Procedures | ||||||
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Laryngectomy | ||||||
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Mastoidectomy | ||||||
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Myringotomy with Insertion of Tubes | ||||||
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Radical Neck | ||||||
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Septoplasty | ||||||
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Tonsillectomy & Adenoidectomy | ||||||
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Tracheostomy | ||||||
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Tympanoplasty | ||||||
| Rating Stars (Click) | CRANIOFACIAL/ORAL/PLASTICS | 1 | 2 | 3 | 4 | ||
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Craniectomy | ||||||
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Craniofacial Reconstruction | ||||||
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Dental Surgery | ||||||
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Leforte 1 Maxillary/Sagittal Osteotomy | ||||||
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ORIF Mandibular Fracture | ||||||
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Otoplasty | ||||||
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Reconstruction of Ear | ||||||
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Removal of Arch Bars | ||||||
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Repair of Cleft Lip, Nose, Palate | ||||||
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Rhinoplasty | ||||||
| Rating Stars (Click) | PLASTIC | 1 | 2 | 3 | 4 | ||
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Blephoroplasty | ||||||
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Breast Reconstruction with Implant | ||||||
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Breast Reduction Mammoplasty | ||||||
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Face Lift | ||||||
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Mastectomy with Tram Flap Reconstruction | ||||||
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Split Thickness Skin Graft | ||||||
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Suction Lipectomy | ||||||
| Rating Stars (Click) | TRANSPLANTS | 1 | 2 | 3 | 4 | ||
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Heart | ||||||
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Lung | ||||||
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Liver | ||||||
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Pancreas | ||||||
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Eye | ||||||
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Organ Donation | ||||||
| Rating Stars (Click) | OPHTHAMOLOGY | 1 | 2 | 3 | 4 | ||
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Cataract Extraction with Implant | ||||||
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Vitrectomy | ||||||
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Scleral Buckle | ||||||
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Cataract Aspiration; Anterior Vitrectomy | ||||||
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Corneal Transplant | ||||||
| If no PEDIATRICS Experience, skip to EQUIPMENT section | |||||||
| Rating Stars (Click) | GENERAL SURGERY | 1 | 2 | 3 | 4 | ||
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Anal Fistulectomy/Anoplasty | ||||||
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Appendectomy/Cholecystectomy | ||||||
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Biopsy (Mass, Muscle, Lymph Node) | ||||||
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Bronchoscopy | ||||||
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Colostomy | ||||||
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Esophagogastroduodenoscopy w/ Biopsy | ||||||
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Esophagoscopy | ||||||
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Exploratory Laparotomy | ||||||
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Flexible Sigmoidoscopy | ||||||
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Fundoplication | ||||||
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Gastrostomy | ||||||
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Herniorrhaphy | ||||||
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Insertion of Port-a-Cath, Hickman, Broviac | ||||||
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Laparascopic General Surgery Procedures | ||||||
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Liver Biopsy | ||||||
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Percutaneous Endoscopic Gastrostomy | ||||||
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Thoracoscopy/Nuss Procedure | ||||||
| Rating Stars (Click) | GENITOURINARY | 1 | 2 | 3 | 4 | ||
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Circumcision | ||||||
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Cystoscopy/Cystogram/Pyelogram | ||||||
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Hydrocelectomy | ||||||
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Nephrectomy | ||||||
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Orchidectomy/Orchidopexy | ||||||
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Repair of Hypospadias | ||||||
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Retrograde Pyelogram | ||||||
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Ureterostomy | ||||||
| Rating Stars (Click) | NEURO | 1 | 2 | 3 | 4 | ||
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Craniotomy | ||||||
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Insertion of Vagal Nerve Stimulator | ||||||
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Insertion of VP Shunt | ||||||
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Laminectomy | ||||||
| Rating Stars (Click) | CARDIAC/VASCULAR | 1 | 2 | 3 | 4 | ||
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Arterial Switch | ||||||
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ASD/VSD Repair | ||||||
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Atrial Septectomy | ||||||
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Bidirectional Glenn | ||||||
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BT Shunt | ||||||
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ECMO Insertion/Decannulation | ||||||
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Fontan Procedure | ||||||
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Norwood Procedure | ||||||
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Pacemaker | ||||||
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PDA Ligation | ||||||
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Repair of Coarctation of Aorta | ||||||
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Ross Procedure | ||||||
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Tetralogy of Fallot Repair | ||||||
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Valve Repair/Replacement | ||||||
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Ventricular Assist Device | ||||||
| Rating Stars (Click) | TRANSPLANT | 1 | 2 | 3 | 4 | ||
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Heart | ||||||
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Kidney | ||||||
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Liver/Pancreas | ||||||
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Lung | ||||||
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Organ Donation | ||||||
| Rating Stars (Click) | OPHTHAMOLOGY | 1 | 2 | 3 | 4 | ||
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Corneal Transplant | ||||||
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Dacrocystorhinostomy | ||||||
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Excision of Chalazion | ||||||
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Eye Muscle Surgery | ||||||
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Levator Resection | ||||||
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Orbitotomy of Eye | ||||||
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Repair of Ptosis | ||||||
| Rating Stars (Click) | EAR/NOSE/THROAT | 1 | 2 | 3 | 4 | ||
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Cochlear Implant | ||||||
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Laryngotracheoplasty | ||||||
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Myringotomy with Tubes | ||||||
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Septoplasty | ||||||
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Suspension Microlaryngoscopy | ||||||
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Tonsillectomy & Adenoidectomy | ||||||
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Tracheostomy | ||||||
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Turbinate Reduction | ||||||
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Tympanoplasty/Typanomastoidectomy | ||||||
| Rating Stars (Click) | CRANIOFACIAL/ORAL/PLASTICS | 1 | 2 | 3 | 4 | ||
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Craniectomy | ||||||
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Craniofacial Reconstruction | ||||||
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Dental Surgery | ||||||
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Leforte 1 Maxillary/Sagittal Osteotomy | ||||||
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Mandibular Osteotomy | ||||||
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ORIF Mandibular Fracture | ||||||
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Otoplasty | ||||||
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Reconstruction of Ear | ||||||
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Repair of Cleft Lip, Nose, Palate | ||||||
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Rhinoplasty | ||||||
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Skin Graft | ||||||
| Rating Stars (Click) | ORTHOPEDICS | 1 | 2 | 3 | 4 | ||
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Acetabuloplasty/Triple Innominate | ||||||
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Arthroscopy of Knee, Wrist, Shoulder | ||||||
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Closed Reduction, Percutaneous Pin | ||||||
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External Fixator (Ilizarov/Orthofix) | ||||||
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ORIF Shoulder, Humerus, Tibia, Femur | ||||||
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Osteotomy/VDRD/Calcaneal/Metatarsal | ||||||
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Spinal Fusion/Spinal with Instrumentation | ||||||
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Tendoachilles Lengthening | ||||||
| Rating Stars (Click) | OR EQUIPMENT | 1 | 2 | 3 | 4 | ||
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Electrocautery (ESU) | ||||||
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Laparoscopy Systems | ||||||
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Neuro | ||||||
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OR Fracture Tables (List types below) | ||||||
| List Types | |||||||
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Orthopedic Total Joint Systems | ||||||
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Power Equipment | ||||||
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Robotics Systems (List types below) | ||||||
| List Types | |||||||
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Spinal Fusion Instrumentation | ||||||
| Rating Stars (Click) | PROFESSIONAL KNOWLEDGE AND SKILLS | 1 | 2 | 3 | 4 | ||
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Malignant Hyperthermia Protocol | ||||||
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Infection Prevention | ||||||
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Isolation Precautions | ||||||
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National Patient Safety Goals/Core Measures | ||||||
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Universal Protocol | ||||||
| Rating Stars (Click) | EMR | 1 | 2 | 3 | 4 | ||
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Epic | ||||||
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Picis | ||||||
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Cerner | ||||||
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Eclipsys | ||||||
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McKesson | ||||||
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Meditech | ||||||
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Other Computerized System | ||||||
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Computerized Physician Order Entry | ||||||
| EMR Conversion | |||||||
| CERTIFICATIONS | Expiry Date : | ||||||
| BLS | |||||||
| Certified Surgical Technologist (CST) | |||||||
| Certified Sterile Processing Technologist (CSPT) | |||||||
| Other: Specify | |||||||
| Rating Stars (Click) | Age Specific Competencies | 1 | 2 | 3 | 4 | ||
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Infant (Birth - 1 year) | ||||||
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Preschooler (ages 2-5 years) | ||||||
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Childhood (ages 6-12 years) | ||||||
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Adolescents (ages 13-21 years) | ||||||
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Young Adults (ages 22-39 years) | ||||||
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Adults (ages 40-64 years) | ||||||
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Older Adults (ages 65-79 years) | ||||||
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Elderly (ages 80+ years) | ||||||