OR First Assist Skills Checklist

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

Years of Pediatrics Experience?
Year of PACU Experience?

General Not Performed Minimal Experience Proficient
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 Not Performed Minimal Experience Proficient
Abdominal Hysterectomy
Vaginal Hysterectomy
A&P Repair
D&C
Laparoscopy
Tubal Ligation
C-Section
Colposcopy
Plastics Not Performed Minimal Experience Proficient
Repair Facial Fractures
Septoplasty
Skin Grafts
Rhinoplasty
Mammoplasty
Facelifts
Muscle Flaps
Abdominalplasty
ENT Not Performed Minimal Experience Proficient
T&A
Myringotomy
Stapedectomy
SMR
Middle Ear Surgery
Endoscopy
Tympanoplasty
Ophthalmologic Not Performed Minimal Experience Proficient
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 Not Performed Minimal Experience Proficient
Vein Harvest
Gastric Artery Harvest
Carotid Endarterectomy
Fem-Pop Bypass Graft
Aortic Aneurysm
Pacemaker Insertion
Orthopedics Not Performed Minimal Experience Proficient
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 Not Performed Minimal Experience Proficient
Cervical Laminectomy
Lumbar Laminectomy
Craniotomy - Tumor
Craniotomy - Aneurysm
Craniotomy - Trauma
Burr Holes
Shunt Procedures VP/VA
Transphenidal Hypophysectomy
Thoracic Not Performed Minimal Experience Proficient
Bronchoscopy
Laryngoscopy
Pneumonectomy
Insertion of Chest Tube
Esophageal Repair
Thoracic Aortic Aneurysm
Mediastinoscopy
Urology Not Performed Minimal Experience Proficient
Cystoscopy
Prostatectomy
Vasectomy
Penile Prosthesis
Hydrocelectomy
TURP
Lithotripsy
Transplant Not Performed Minimal Experience Proficient
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
Bone - Transplant
Cardiac Not Performed Minimal Experience Proficient
Septal Defects
Angioplasty
Coronary Artery Bypass Graft
Mitral Valve Replacement
Aortic Valve Replacement
Ventricular Aneurysm Repair
Pericardectomy
Insertion of Internal Pacemaker
Femoral Artery Cannulation

Signature: Date:

Agency Signature: __________________________________