Operating Room Skills Checklist
Answer Key
1. No Experience 2. Requires Supervision 3. Proficient 4. Can Teach Others
Age Specific
*
Rows
1
2
3
4
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)
Work Settings
*
Rows
1
2
3
4
General OR
CVOR
Outpatient
Trauma
Peds-General OR
Peds-CVOR
First Assist
Scrub Experience
Robots / Da Vinci
Case Experience
General Surgery: CIRCULATE
*
Rows
1
2
3
4
Appendectomy
Breast Biopsy
Cholecystectomy
Abdominal-Perineal Resection
Bowel/Colon Resection
Hernia Repair
Thyroidectomy
Splenectomy
Vein Stripping
Radical Mastectomy
Tracheostomy
Gastrectomy
Hickman/Groshong/Portacath Insertion
Cholecystectomy
Hernia Repair
Bowel
Nissen
Bariatric
General Surgery: SCRUB
*
Rows
1
2
3
4
Appendectomy
Breast Biopsy
Cholecystectomy
Abdominal-Perineal Resection
Bowel/Colon Resection
Hernia Repair
Thyroidectomy
Splenectomy
Vein Stripping
Radical Mastectomy
Tracheostomy
Gastrectomy
Hickman/Groshong/Portacath Insertion
Cholecystectomy
Hernia Repair
Bowel
Nissen
Bariatric
Thoracic/CV: CIRCULATE
*
Rows
1
2
3
4
Abdominal Aortic Aneurysm
Aortic-Femoral Bypass Graft
AV Shunt/Graft
Carotid Endarterectomy
Lobectomy
Mediastinoscopy
Thoracoscopy
Thoracotomy
Thoracic/CV: SCRUB
*
Rows
1
2
3
4
Abdominal Aortic Aneurysm
Aortic-Femoral Bypass Graft
AV Shunt/Graft
Carotid Endarterectomy
Lobectomy
Mediastinoscopy
Thoracoscopy
Thoracotomy
Orthopedic/Podiatry: CIRCULATE
*
Rows
1
2
3
4
Knee Arthroscopy
ACL Repair
Shoulder Arthroscopy
Endoscopic Shoulder Repair
Open Shoulder Repair
Total Knee Replacement/Revision
Total Hip Replacement/Revision
Bipolar Hip Replacement
Hip Compression Nails and Lag Screw
Hand Surgery
External Fixation Devices
IM Roddings
Bunionectomy
Spinal Fusion With Instrumentation
Harrington Rod Insertion
Carpal Tunnel Repair
Chick Fracture Table
ORIF With Compression Set
Closed Reduction Fracture
Orthopedic/Podiatry: SCRUB
*
Rows
1
2
3
4
Knee Arthroscopy
ACL Repair
Shoulder Arthroscopy
Endoscopic Shoulder Repair
Open Shoulder Repair
Total Knee Replacement/Revision
Total Hip Replacement/Revision
Bipolar Hip Replacement
Hip Compression Nails and Lag Screw
Hand Surgery
External Fixation Devices
IM Roddings
Bunionectomy
Spinal Fusion With Instrumentation
Harrington Rod Insertion
Carpal Tunnel Repair
Chick Fracture Table
ORIF With Compression Set
Closed Reduction Fracture
Equipment Experience
*
Rows
1
2
3
4
Argon Beam Coagulator
Brown Dermatome
Crainotome
Cry-Ophthalmic Unit
Fragmatomore
Leg Holder
Neoprobe
Pena Stimulator
Sternal Saw
Vac-Pac Positioner/Bean Bag
Wilson Frame
Brainlab Navigation
Chick Table
Emerson Thoracic Pump
Eye Magnet
Laser
Midas Rex
Nitrous Oxide Bank
Spy Fluorescence Machine
Sterrad Machine
Vacuum Curettage
Zimmer Dermatome
Bair Hugger
Candy Cane Stirrups
Cryomachine
Extremity Microscope
Image Intensifier
Microscopic Instruments
Nerve Stimulator
Pneumatic Tourniquet
Sterilizer
Ultrasonic Cleaner
Water Pik
Allen Stirrups
Bipolar Cautery
Cell Saver
Electrosurgical Unit
Fracture Tables
Gardner-Wells Tongs
Mayfield Headrest
Ohio Suction Units
Stealth Navigation
Stryker Drills
Washer Sanitizer
Procedures
*
Rows
1
2
3
4
Donning of Surgical Attire
Aseptic Technique
Procedure Set Up
Hemodynamic Monitoring During Anesthesia
Sponge & Lap Counts
Airway Maintenance
Patient Charge Capture Systems
Patient Prep
Medications & Therapeutic Interventions
IV Therapy
*
Rows
1
2
3
4
Assist with IA/IV Therapy
PIV Insertion
Admin Blood/Blood Products
Central Vascular Access Device
Care/Maintenance
Pain Management/Anesthesia
*
Rows
1
2
3
4
General Anesthesia
Positioning Patients for Anesthesia
Epidural Anesthesia/Analgesia
Spinal
Moderate Sedation
Assess Pain Level/Tolerance
Regional Anesthesia
Malignant Hyperthermia
Anesthesia Toxicity
Signs & Symptoms of Dural Puncture
Oxygen Administration
*
Rows
1
2
3
4
Nasal Cannula
Trach Collar
Non-Rebreather Mask
Ventilator
Ambu-Bag
Tracheostomy
Portable Oxygen
Venturi Masks
Undertaking
*
The Information I Provided is True & Accurate
Name Signature
*
Date
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: