Operating Room Skills Checklist

Date:
First Name:
Last Name:
Email:
Phone Number:
Cell Phone:

Years of Pediatrics Experience?
Years of PACU Experience?

Not Performed = 1    •    Minimal Experience = 2    •    Proficient = 3

  Scrub   Circulate
General 1 2 3   1 2 3
Esophagoscopy  
Esophageal Resection  
Gastroscopy  
Hernia Repairs  
Splenectomy  
Bowel Repairs/Resections  
Thyroidectomy  
Appendectomy  
Cholecystectomy  
Mastectomy  
Amputations  
Vagotomy/Pyloraplasty  
Pancreatectomy  
Hernia  
Colectomy  
Exploratory/Laproscopy  
Nephrectomy  
OB/GYN 1 2 3   1 2 3
Abdominal Hysterectomy  
Vaginal Hysterectomy  
A&P Repair  
D&C  
Laparoscopy  
Tubal Ligation  
C-Section  
Colposcopy  
Plastics 1 2 3   1 2 3
Repair Facial Fractures  
Septoplasty  
Skin Grafts  
Rhinoplasty  
Mammoplasty  
Facelifts  
Muscle Flaps  
Abdominalplasty  
ENT 1 2 3   1 2 3
T&A  
Myringotomy  
Stapedectomy  
SMR  
Middle Ear Surgery  
Endoscopy  
Tympanoplasty  
Ophthalmologic 1 2 3   1 2 3
Iridectomy  
Cataract Extraction  
Dacryocystecstomy  
Dacryocystorhinostomy  
Diathermy  
Enucleation  
Lid & Muscle Procedures  
Orbital Implant  
Phaco Emulsification  
Pterygium Repair  
Recession Resection  
Repair of Fracture  
Scleral Buckle  
Vitrectomy  
Corneal Transplant  
Vascular 1 2 3   1 2 3
Vein Harvest  
Gastric Artery Harvest  
Carotid Endarterectomy  
Fem-Pop Bypass Graft  
Aortic Aneurysm  
Pacemaker Insertion  
Orthopedics 1 2 3   1 2 3
Total Hip Replacement  
Total Knee Replacement  
Fracture Repair with Compression  
Arthroscopy - Knee  
Arthroscopy - Shoulder  
IM Rods  
External Fixations  
Laminectomy  
Spinal Infusion  
Cast Application  
Hand Surgery/Fracture Repairs  
Foot Procedure/Fractures  
Neurology 1 2 3   1 2 3
Cervical Laminectomy  
Lumbar Laminectomy  
Craniotomy - Tumor  
Craniotomy - Aneurysm  
Craniotomy - Trauma  
Burr Holes  
Shunt Procedures VP/VA  
Transphenidal Hypophysectomy  
Thoracic 1 2 3   1 2 3
Bronchoscopy  
Laryngoscopy  
Pneumonectomy  
Insertion of Chest Tube  
Esophageal Repair  
Thoracic Aortic Aneurysm  
Mediastinoscopy  
Urology 1 2 3   1 2 3
Cystoscopy  
Prostatectomy  
Vasectomy  
Penile Prosthesis  
Hydrocelectomy  
TURP  
Lithotripsy  
Transplant 1 2 3   1 2 3
Renal - Harvest  
Renal - Transplant  
Liver - Harvest  
Liver - Transplant  
Heart - Harvest  
Heart - Transplant  
Eye - Harvest  
Eye - Transplant  
Skin - Harvest  
Skin - Transplant  
Lung - Harvest  
Lung - Transplant  
Pancreas - Harvest  
Pancreas - Transplant  
Bone - Harvest