Skills Checklist – Operating Room Skills Checklist – Operating Room Name First Last Phone Email GENERAL SURGICAL* Rarely Some Experience Proficient Trainer / Preceptor N/A Abdominal Perineal Resection Appendectomy Breast Biopsy Central Line Insertion Cholecystectomy/cholangiogram Colon Resection Herniorrhaphy Radical Mastectomy Splenectomy Thyroidectomy * Rarely Some Experience Proficient Trainer / Preceptor N/A GENERAL SURGICAL – Herniorrhaphy* Rarely Some Experience Proficient Trainer / Preceptor N/A Inguinal Umbilical Hiatal Herniorrhaphy CARDIOTHORACIC* Rarely Some Experience Proficient Trainer / Preceptor N/A CABG Chest Tube Insertion Closed Thoracotomy Coarctation Resection, Aorta CARDIOTHORACIC – OPEN HEART PROCEDURES* Rarely Some Experience Proficient Trainer / Preceptor N/A Pacemaker Implantation Vein Harvesting NEUROSURGICAL* Rarely Some Experience Proficient Trainer / Preceptor N/A A-V Malformation Ant. Laparoscopic Spine Procedure Burr Holes for Subdural Hematoma Carotid Ligation Cervical Fusion Cranioplasty/Craniotomy Aneurysm Clipping Craniectomy for Decompression Fx Crutchfield Tong Insertion Discectomy Medication Pump Insertion Pedicle Screw Insertion Shunt Procedure, VP & VA Ventriculostomy ENDOSCOPIC* Rarely Some Experience Proficient Trainer / Preceptor N/A Bronchoscopy Colonscopy Cystoscopy Gastroscopy Hyteroscopy ENDOSCOPIC – LAPRAOSCOPY* Rarely Some Experience Proficient Trainer / Preceptor N/A Appendectomy Cholecystectomy Cholangiogram Colon Resection Herniorrhaphy Salpingo-Oophorectomy Tubal Ligation Scope Assisted Vaginal Hysterectomy Sigmoidoscopy ORTHOPEDIC* Rarely Some Experience Proficient Trainer / Preceptor N/A Acetabular/Pelvic ORIF Anterior Cruciate Ligament Repair Arthroscopy Bipolar/Unipolar Hips Bunionectomy Calcaneal Reconstruction Carpel Tunnel Release External Fixator Application Hip Compression & Lag Screws Intramedullary Rods Insertion Laminectomy Rotator Cuff Repair Sacro-iliac Joint Screws Spinal Fusion Total Joint Replacement GYNECOLOGIC* Rarely Some Experience Proficient Trainer / Preceptor N/A Cesarean Section Ectopic Pregnancy Hysterectomy Ovarian Cystectomy Salpingoplasty VASCULAR* Rarely Some Experience Proficient Trainer / Preceptor N/A A-V Access Graft Aortic aneurysm w/ graft replacement Carotid aneurysm resection & graft Endarterectomy Stent Placements Thrombectomy/Embolectomy Vena Cava Ligation UROLOGIC* Rarely Some Experience Proficient Trainer / Preceptor N/A Bladder Suspension Hypospadias Repair Nephrolithotomy Orchiopexy Prostatectomy Perineal Suprapubic TURP/TURBP Vasectomy ORAL* Rarely Some Experience Proficient Trainer / Preceptor N/A Closed Reduction Facial Fractures Excision Odontoma Fractured Jaws OTORHINOLARYNGOLOGIC* Rarely Some Experience Proficient Trainer / Preceptor N/A Adenoidectomy Cleft Lip/Palate Repair Closed Reduction Nasal Fracture Laryngectomy Open Reduction Facial Fractures Nasal Fractures Radical Neck Dissection OTORHINOLARYNGOLOGIC – SELECTIVE OSTEOTOMY* Rarely Some Experience Proficient Trainer / Preceptor N/A Maxilla Mandible Sinus Endoscopy Sinusotomy Stapedectomy Tonsillectomy Tracheostomy Tympanoplasty Ophthalmologic Scleral Buckle Vitrectomy PLASTIC* Rarely Some Experience Proficient Trainer / Preceptor N/A Abdominal Lipectomy Free Flaps PLASTIC – MAMMOPLASTY* Rarely Some Experience Proficient Trainer / Preceptor N/A Augmentation Reduction TRAM Flap Mentoplasty Otoplasty Scar Revisions Split Thickness Skin Grafting Tissue Expanders TRANSPLANT* Rarely Some Experience Proficient Trainer / Preceptor N/A Bone Bone Marrow Corneal Heart Kidney Liver Lung Pancreas Harvesting TRAUMA* Rarely Some Experience Proficient Trainer / Preceptor N/A Burns Gunshot/Stab Wounds Skills / Procedures* Rarely Some Experience Proficient Trainer / Preceptor N/A Blood/Blood Product Infusion Foley Catheter Insertion & Care Intubation Extubation Intravenous Therapy Malignant Hyperthermia Crisis Oxygen Therapy Administration Suctioning Temperature Wound Care EQUIPMENT & SUPPLIES* Rarely Some Experience Proficient Trainer / Preceptor N/A Autoclave Bair Hugger Blood/Fluid Warmer Camera/Video Systems Dermatome Drills Fracture Tables Laser Infusion Delivery Devices (specify) DEVICE #1 DEVICE #2 DEVICE #3 INFUSION DELIVERY DEVICE EXPERIENCE Rarely Some Experience Proficient Trainer / Preceptor N/A Infusion Device #1 Infusion Device #2 Infusion Device #3 PAIN MANAGEMENT* Rarely Some Experience Proficient Trainer / Preceptor N/A Pain Level Assessment PAIN MANAGEMENT – CARE OF PATIENT WITH* Rarely Some Experience Proficient Trainer / Preceptor N/A Epidural Anesthesia IV Conscious Sedation PCA Narcotic Agents PRIMARY OR EXPERIENCE (# OF YEARS) Endoscopy Cardiothoracic General Surgery Gynecologic Neurosurgical Ophthalmologic Oral Orthopedic Otorhinolaryngologic Plastic Transplant Trauma Urologic Vascular * Rarely Some Experience Proficient Trainer / Preceptor N/A * Rarely Some Experience Proficient Trainer / Preceptor N/A Do you speak any languages other than English?* No If yes, enter languages above, separated by commas. Age Group Experience* Rarely Some Experience Proficient Trainer / Preceptor N/A Newborn (birth – 30 days) Infant (30 days – 1 year) Toddler (1 – 3 years) Preschooler (3 – 5 years) School Age (5 – 12 years) Adolescents (12 – 18 years) Young Adults (18 – 39 years) Middle Adults (39-64 years) Older Adults (64+ years) Confirmation* I attest that the information I have given is both true and, to the best of my knowledge, represents an accurate self assessment of my professional skills and/or education. Signature Date Date Format: MM slash DD slash YYYY