This checklist was electronically signed on (Today’s date)
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
Start peripheral IV - angio cath
Insertion of A-lines
Insertion of CVP - jugular
Insertion of CVP - sublavian
Insertion of Swan-Ganz
Drawing blood from central line
Drawing venous blood
Packed red blood cells
Plasma/Albumin
Whole blood
Abdominal perineal resection
Adrenalectomy
Anal fissurectomy
Appendectomy
Bowel resection
Breast biopsy
Cholecystectomy (open)
Colectomy
Colostomy/ileostomy
Esophogeal resection
Exploratory laparotomy
Gastrectomy
Gastroplasty
Hemorrhoidectomy
Hemicolectomy
Hepatic resection
Herniorrhaphy - femora
Herniorrhaphy - inguina
Herniorrhaphy - umbilical
Herniorrhaphyhiatal transabdominal/transthoracic
Hiatal hernia repair
Insertion - Hickman
Insertion - Groshong
Insertion - Portacath
Hydroceletomy
Imperforate anus reconstruction
Lumbar sympathectomy
Omphalocele repair
Pancreatectomy / pancreatogram
Pilonidal cystectomy
Portal caval shunt
Pyloric stenosis
Radical mastectomy
Saphenous vein ligation and stripping
Sentinel node biopsy
Splenectomy
Tenchknoff duct cyst excision
Thyroglossal duct cyst excision
Thryoidectomy
Vagotomy
Cervical rib excision
Chamberlain procedure
Closed thoracotomy
Correction pectus excavatum
Esophagectomy
Heller procedure
Mitral commissurotomy
Mitral or aortic valve replacement
IAPB insertion
CABG
Cardiac valve replacement
Patent ductus arteriosus repair
Septal defect repairs
Pacemaker implanation - endocardial
Pacemaker implanation - myocardia
Pacemaker - temporary
Pericardiectomy
Pericardial window
Resection coarctation aorta
Portocaval shunt
Tetrology of fallot
Thoracoplasty
Tracheal resection
Transthoracic diaphragmatic heniorrhaphy
A-V access graft
Aortic aneurysm with graft replacement
Endarterectomy/carotid - femoral
Fem-pop bypass
Peripheral vascular bypass procedures
Resection carotid aneurysm with graft
Thrombectomy/embolectomy
Vena cava filter/umbrella
A-V malformation
Anterior cervical fusion
Anterior laparoscopic spine procedures
Anterior lumbar interbody fusion (ALIF)
Burr holes for subdural hematoma
Carotid ligation
Cervical sympathectomy
Craniectomy for decompression fracture
Discetomy
Hypophysectomy
Insertion nerve stimulators
Insertion medication pumps
Laminectomy
Myelomeningocele repair
Pedicle screw insertion
Posterior lumbar interbody fusion (PLIF)
Shunt procedure/VP, VA/LP
Spine fusion
Ulnar nerve transfer
Ventriculography / ventriculoscopy
Ventriculostomy
Clipping of aneurysm
Tumor excision
Stealth crainiotomy
Adult circumcision
Cystectomy
Cystoscopy/ureteroscopy
Hypospadias repair
Ileal loop
Implants - penile and testicular
Lithotripsy
Nephrectomy
Nephrolithotomy
Orchiopexy
Prostatectomy - perineal
Prostatectomy - supra-pubic
Pyleoplasty
Radical node dissection
Scott incontinence device
TURP
Ureterolithotomy
Vasectomy
Vasovasostomy
Waterhouse procedure
Cesarean section
Colpotomy
Dilation and curettage (DandC)
Hysterectomy - abdominal
Hysterectomy - vaginal
Marshall - Marchetti
Marsupialization, Bartholin cyst
Ovarian cystectomy
Radium insertion
Salpingo-oophorectomy
Sacral spinus fixation
Shirodkar procedure
Suction curettage
Termination of pregnancy
Tubal ligation
Vaginal recontruction
Vaginectomy/vulvectomy
Acetabular/pelvic ORIF
Achilles tendon repair
Amputation- leg, arm
Application of external fixators - extremeties
Application of external fixators - pelvis
Application of halo traction
Arthrotomy
Bunionectomy
Calcanel reconstruction
Capsulorrhaphy
Carpal tunnel release
Closed reduction fracture
Hand surgery with implants
Harrington rod instrumentation and / or Dwyer procedure
Heel cord lengthening
Olecranon bursa, excision of
ORIF, internal fixation with compression set
Patellectomy
PuttiPlatt/Bankart procedure/rotator cuff repair
Reduction with compression sets
Reimplanation of digits
Sacro-iliac (SI) joint screws
Sharrard procedure
Spica cast, application
Spinal fusion
Tendon transplants (hand and foot)
Orthopedics - Arthroscopy
Ankle
Elbow
Knee
Shoulder
Jewett
Kuntscher rod
Lottes
Rush
Schneider
Zimmer
Iliac crest bone graft
Insertion Austin Moore hip prosthesis
Extraction
Femoral
Humeral
Insertion
Supracondylar
Tibal
Hip
Abdominal lipectomy
Abdominalplasty
Blepharoplasty
Cleft lip repair
Dermabrasion
Face lift
Mentoplasty
Otoplasty
Pedicle grafts
Rhytidectomy
Scar revisions
Split thickness skin grafting
Tissue expanders
Augmentation
Reduction
Tramflaps with reconstructive mammoplasty
Adenoidectomy
Caldwell - Luc
Cleft lip/palate repair
Closed reduction nasal fx
Ethmoidectomy
Excision of salivary gland tumor
Fenestration procedure
Frontal flap sinus procedure
Glossectomy
Laryngectomy
Mandibulectomy
Mastoidectomy
Maxillary advancement with graft
Maxillectomy
Myringoplasty
Myringotomy with PE tube insertion
Nasal polypectomy
Open reducation facial fx
Open reducation nasal fx
Parotidectomy
Pharyngeal flap procedure
Radical neck dissection
Ranulectomy
Rhinoplasty/septoplasty
Selective osteotomy of maxilla/mandible
Sinus endoscopy
Sinusotomy
Stapedectomy
Submucous resection
Tonsillectomy
Tracheostomy
Tympanoplasty
Closed reducation facial fractures/wiring
Excision odontoma
Excision of deciduous teeth
Extraction of impacted molars
Fractured jaws, mandibular and zagomatic
Ginivectomy
LeFort osteotomies
Maxillary procedure with graft
Pediatric dentistry
Sagittal osteotomy
Temporomandibular (TMJ) with arthroplasty
TMJ exploration
Cataract extraction with IOL
Corneal transplant
Dacryocystectomy
Eye enucleation
Exicison of chalazion
Canthotomy
Correction of ectropian/entropian
Enucleation
Eye transplant
Iridectomy
Lacrimal duct probing
Lid and muscle procedures
Orbital implant
Ptergium repair
Recession resection
Refractive keratoplasty
Repair orbital blowout fracture
Repair of retinal detachment
Scleral buckle
Vitrectomy
Bronchoscopy
Colonscopy
Culdoscopy
Esophagoscopy
Gastroscopy
Hysteroscopy
Bone marrow
Bone
Harvesting
Heart
Kidney
Liver
Lung
Multi-organ
Pancreas
Skin
Burns
Motor vehile accidents (multiple injuries)
Traumatic amputations
Abdomen
Chest
Head
Argon beam coagulator
Bair hugger
Blood/fluid warmer
Cardiac monitor and pacemaker
Cell saver
Cidex soak
Cry-opthalmic unit
Defibrillator/pacer
Electrosurgical unit
Emerson thoracic pump
ETO sterilizer
Eye magnet
Fiber optic luminator
Flash autoclave
Hypo/hyperthemia units
Kreiselman resuscitor
Mesh graft
MicroscopesNerve stimulatorNitrous oxide bank
Nitrous oxide bank
Ohio suction units
Orthopedic arm board with drain
Pleurevac disp. chest drainage
Pneumatic tourniquet
Sterad machine
Steri-vac aeratopm cabinet
Steris unit
Tele therometer
Ultrasonic cleaner
Vac-pac positioner
Vacuum curettage
Washer sanitizer
Washer sterilizer
Chick/Marquet tables
Jackson table
Rush/Skytron tables
GIA
EEA
LDS
TA
CO2
Yag
Other
Camera controller
Light source
Printers
VCRs
Brown
Padgett
Disposable grounding pads
3-M maxi driver
Codman craniotome
Hall air-driver
Hall dental
Midax Rex/Anspach
Stryker drills - large battery
Stryker drills - small battery
Surgairtome
Synthes A-O drill
Miscellaneous
Assist with intubation
Conscious sediation administration
Conscious sediation monitoring
A.Newborn/Neonate (birth - 30 days)
B.Infant (30 days - 1 year)
C.Toddler (1 - 3 years)
D.Preschooler (3 - 5 years)
E.School age children (5 - 12 years)
F.Adolescents (12 - 18 years)
G.Young adults (18 - 39 years)
H.Middle adults (39 - 64 years)
I.Older adults (64+)
H.Middle adults (39 - 64 years
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