OR Skills Check List Name First Last Date MM slash DD slash YYYY Certification DatesBCLS MM slash DD slash YYYY ACLS MM slash DD slash YYYY Chemo MM slash DD slash YYYY CCRN MM slash DD slash YYYY Other Other Date MM slash DD slash YYYY 1 = Never Performed 2 = Some Experience 3 = Proficient/Can Perform DutiesEquipment OperationSteam Sterilizer 1 2 3 Electrosurgical Unit 1 2 3 OR Tables 1 2 3 Overhead Lights 1 2 3 Light Sources & Headlights 1 2 3 K-Thermia Unit 1 2 3 OptomologyResection/Recession 1 2 3 Cataract Extraction 1 2 3 Scleral Bleeding 1 2 3 Vitrectomy 1 2 3 Cyro Procedure 1 2 3 Cataract Extraction w/ Intraoccular Implant 1 2 3 PlasticsSuction Lipectomy 1 2 3 Mammoplasty 1 2 3 Skin Grafts 1 2 3 Cleft Lip/Palate 1 2 3 Implants 1 2 3 Facial Fractures 1 2 3 Teeth Extractions 1 2 3 Resection Maxilla/Mandible 1 2 3 PediatricsPylormyotomy 1 2 3 Insertion Central Line 1 2 3 Inguinal Hernia 1 2 3 Laparotomy 1 2 3 P.D.A. Ligation 1 2 3 Hypospadius Repair 1 2 3 NeurosurgeryCraniotomy 1 2 3 V-P Shunt 1 2 3 Burr Holes 1 2 3 Cranioplasty 1 2 3 Anterior Cervical Fusion 1 2 3 Applications of Halo 1 2 3 Other 1 2 3 1 2 3 1 2 3 General SurgeryExploratory Laparotomy 1 2 3 Herniorraphy 1 2 3 Breast Biopsy 1 2 3 Radical/Modified Mastectomy 1 2 3 Appendectomy 1 2 3 Cholecystectomy 1 2 3 Laparoscopic Cholecystectomy 1 2 3 Gastrectomy 1 2 3 Colon Resection 1 2 3 Abdominal-Perineal Resection 1 2 3 Mediastinoscopy 1 2 3 Thyroidectomy 1 2 3 Hemorrhoidectomy 1 2 3 Broviac Catheter Insertion 1 2 3 Amputations 1 2 3 Hiatal Hernia Repair 1 2 3 Splenectomy 1 2 3 Endocopies 1 2 3 Internal Staples 1 2 3 OrthopedicsEmergency Trauma 1 2 3 Arthroscopy w/ Shaving 1 2 3 Arthrotomy 1 2 3 Laminectomies: Lumbar 1 2 3 Laminectomies: Cervical 1 2 3 Spinal Fusions 1 2 3 Anterior Cervical Fusions 1 2 3 Hip Prosthesis 1 2 3 Total Joint Replacement 1 2 3 ORIF Ankles, Tibias, Femur, etc. 1 2 3 Bunionectomy 1 2 3 Application Spica Cast 1 2 3 Hand Cases 1 2 3 Tendon & Nerve Repairs 1 2 3 Closed Reduction & Fixation 1 2 3 Acrominoplasty 1 2 3 External Fixations 1 2 3 Operation of Drills & Saws 1 2 3 Internal Compression Plates & Screws 1 2 3 External Compression Devices 1 2 3 Rods 1 2 3 K-Wires/Steinman Pins 1 2 3 Hip Compression Plates & Screws 1 2 3 General Nursing DutiesCharge Duties 1 2 3 Sponge & Sharp Instrument Counts 1 2 3 Surgical Hand Scrub, Gowning & Gloving 1 2 3 Preoperative Patient Assessment 1 2 3 Patient Positioning 1 2 3 Intraoperative Documentation 1 2 3 Care of Specimens 1 2 3 Emergency Procedure in the OR 1 2 3 Chemical Disinfections Procedure 1 2 3 EquipmentLaser 1 2 3 Fragmatome 1 2 3 Occutome 1 2 3 Phaco 1 2 3 Microscope 1 2 3 Cryomachine 1 2 3 Microirrigator 1 2 3 Laparascopy Machine 1 2 3 Suction Curettage Machine 1 2 3 Ultrasound Machine 1 2 3 Lithotripsy Machine 1 2 3 UrologyCystoscopy 1 2 3 TURP 1 2 3 Cysto/Bladder Biopsy 1 2 3 Lithotripsy 1 2 3 Vasovasostomy 1 2 3 Nephrolithotomy 1 2 3 Nephrectomy 1 2 3 Illeal Loop/Cystectomy 1 2 3 Testicular Biopsy 1 2 3 Orchiectomy Orchiopexy 1 2 3 Renal Transplant 1 2 3 Hydrocelectomy 1 2 3 Suprapubic Prostatectomy 1 2 3 Care & Handling of Cysto Instruments 1 2 3 Experience with Implants 1 2 3 GynecologyAbdominal Hysterectomy 1 2 3 Vaginal Hysterectomy 1 2 3 Laparoscopy 1 2 3 D & C 1 2 3 Anterior/Posterior Repair 1 2 3 Bilateral Tubal Ligation 1 2 3 Hysteroscopy 1 2 3 Pelviscopy 1 2 3 ENTEndoscopic Nasal Procedures 1 2 3 T & A 1 2 3 Myringotomy 1 2 3 Laryngo-, Broncho-, Esophago-scopies 1 2 3 Tracheostomy 1 2 3 Radia Neck Dissection 1 2 3 Intra-Aortic Balloon 1 2 3 Grafts 1 2 3 CardiovascularAbdominal Aortic Aneurysm 1 2 3 Bypasses 1 2 3 Valve Replacements 1 2 3 Endarterectomies 1 2 3 Pacemaker Insertion 1 2 3 Thoracotomy 1 2 3 Intra-Aortic Balloon 1 2 3 Grafts 1 2 3 Preparation of Chest Tubes & Bottles 1 2 3 Laser SurgeriesType: Type: Type: 1 2 3 1 2 3 1 2 3
