Orthopedic Skills Checklist

Orthopedic Skills Checklist

First Name*

Last Name*

Years of Experience*

E-mail

example@example.com

ANSWER KEY

PROFICIENCY

1=Not Applicable 2=No Experience 3=Some Experience

4=Experienced 5=Very Experienced

FREQUENCY

1=Never Performed 2=Assisted Only 3=Rarely Performed

4=Occasionally Performed 5=Regularly Performed

General*

	Proficiency	Frequency
Long Arm Pronation or Supination
Short Arm in Neutral Position
Short Arm in Flexion With Ulnar Deviation With 3 Point Molding
Short Leg Non-Weight Bearing in Equines
Toe Plates Applied to Short and Long Leg Casts
Long Arm Navicular Thumb Spica
Skills-Casts-Fiberglass / Synthetic
Long Arm in Flexion With Ulnar Deviation With 3 Point Molding
Short Leg Walking in Neutral Position
Short Leg Walking in Equines
Short Leg Non-Weight Bearing in Neutral Position
P.T.B With Correct Molding
Long Leg Walker
Cylinder Cast
Long Leg Non-Weight Bearing in Neutral Position With Correct Knee Flexion
Long Leg Non-Weight Bearing With Molding for Widened Mortise
Gauntlet With Outrigger-Hand
Gauntlet With Outrigger and Molding-Hand
Long Arm Thumb Spica

Cast Saw*

	Proficiency	Frequency
Trim Casts
Remove and Replace Cast Blades
Remove Casts
Wedging
Window Casts
Univalve Casts

General*

	Proficiency	Frequency
Thumb Spica
Hand Muff Splint
Foot Muff Splint
Sugar Tong Double Long Arm
Short Leg Posterior
Gutter Splint Lateral and Medial
Short Arm Volar
Long Arm Posterior With Side Walls
Sugar Tong Short Long

General*

	Proficiency	Frequency
Ace Bandage
Shoulder Immobilizer
Slings
Hinged Knee Brace
Wrist Brace
Velcro Knee Brace
Cervical Collar - Hard
Cervical Collar - Soft

General*

	Proficiency	Frequency
Overhead Bed Frame
Splint Russells
Assist MD With Fracture Reduction
Cervical
Bucks
Bryant's
Balanced Suspension

General*

	Proficiency	Frequency
Gait Training
Range of Motion Exercises
Crutches and Canes
Crutches and Canes - Fitting
Crutches and Canes - Instructions

General*

	Proficiency	Frequency
Removal of Sutures
Making Various Casts and Molds
Preparing Plaster of Paris Mix
Removal of Orthopedic Devices
Make Alterations to Casts to Alleviate Pressure Points
Assisting With Research Projects
Assist With Skin Grafts
Assist With Stump Revisions
Assist With Pin Insertions
Assist With Debridements
Application of Minerva / Halo Jacket
Sterile Dressing Techniques

Age Specific Criteria*

	Proficiency	Frequency
Newborn / Neonatal (up to 30 days)
Infant (30 days to 1 year)
Toddler (1 to 3 years)
Preschooler (3 to 5 years)
School Age (5 to 12 years)
Adolescents (12 to 18 years)
Young Adults (18 to 39 years)
Middle Adults (40 to 64 years)
Older Adults (65 & up)

The information provided is true and to the best of my knowledge. I hereby authorize Summit Medical Staffing to present my Skills Checklist to facilities for the purpose of employment. Please Type Your Name in This Box to Electronically Sign this Form.*

First NameLast Name

Date*

MonthDayYear

Hour MinutesAM/PM Option

Form Reply Email Address

Salesforce Check

Skills-Casts-Fiberglass / Synthetic

Skills - Splints

Braces & Immobilizers

Traction

Physical Therapy

Miscellaneous