Skills Checklist - Operating Room - Origin Travel Nurses

GENERAL SURGICAL*

	Rarely	Some Experience	Proficient	Trainer / Preceptor	N/A
Abdominal Perineal Resection
Appendectomy
Breast Biopsy
Central Line Insertion
Cholecystectomy/cholangiogram
Colon Resection
Herniorrhaphy
Radical Mastectomy
Splenectomy
Thyroidectomy

GENERAL SURGICAL - Herniorrhaphy*
Rarely Some Experience Proficient Trainer / Preceptor N/A
Inguinal
Umbilical
Hiatal Herniorrhaphy
CARDIOTHORACIC*
Rarely Some Experience Proficient Trainer / Preceptor N/A
CABG
Chest Tube Insertion
Closed Thoracotomy
Coarctation Resection, Aorta
CARDIOTHORACIC - OPEN HEART PROCEDURES*
Rarely Some Experience Proficient Trainer / Preceptor N/A
Pacemaker Implantation
Vein Harvesting

NEUROSURGICAL*

	Rarely	Some Experience	Proficient	Trainer / Preceptor	N/A
A-V Malformation
Ant. Laparoscopic Spine Procedure
Burr Holes for Subdural Hematoma
Carotid Ligation
Cervical Fusion
Cranioplasty/Craniotomy
Aneurysm Clipping
Craniectomy for Decompression Fx
Crutchfield Tong Insertion
Discectomy
Medication Pump Insertion
Pedicle Screw Insertion
Shunt Procedure, VP & VA
Ventriculostomy

ENDOSCOPIC - LAPRAOSCOPY*

	Rarely	Some Experience	Proficient	Trainer / Preceptor	N/A
Appendectomy
Cholecystectomy
Cholangiogram
Colon Resection
Herniorrhaphy
Salpingo-Oophorectomy
Tubal Ligation
Scope Assisted Vaginal Hysterectomy
Sigmoidoscopy

ORTHOPEDIC*

	Rarely	Some Experience	Proficient	Trainer / Preceptor	N/A
Acetabular/Pelvic ORIF
Anterior Cruciate Ligament Repair
Arthroscopy
Bipolar/Unipolar Hips
Bunionectomy
Calcaneal Reconstruction
Carpel Tunnel Release
External Fixator Application
Hip Compression & Lag Screws
Intramedullary Rods Insertion
Laminectomy
Rotator Cuff Repair
Sacro-iliac Joint Screws
Spinal Fusion
Total Joint Replacement

VASCULAR*

	Rarely	Some Experience	Proficient	Trainer / Preceptor	N/A
A-V Access Graft
Aortic aneurysm w/ graft replacement
Carotid aneurysm resection & graft
Endarterectomy
Stent Placements
Thrombectomy/Embolectomy
Vena Cava Ligation

UROLOGIC*
Rarely Some Experience Proficient Trainer / Preceptor N/A
Bladder Suspension
Hypospadias Repair
Nephrolithotomy
Orchiopexy
Prostatectomy
Perineal
Suprapubic
TURP/TURBP
Vasectomy
ORAL*
Rarely Some Experience Proficient Trainer / Preceptor N/A
Closed Reduction Facial Fractures
Excision Odontoma
Fractured Jaws
OTORHINOLARYNGOLOGIC*
Rarely Some Experience Proficient Trainer / Preceptor N/A
Adenoidectomy
Cleft Lip/Palate Repair
Closed Reduction Nasal Fracture
Laryngectomy
Open Reduction
Facial Fractures
Nasal Fractures
Radical Neck Dissection
OTORHINOLARYNGOLOGIC - SELECTIVE OSTEOTOMY*
Rarely Some Experience Proficient Trainer / Preceptor N/A
Maxilla
Mandible
Sinus Endoscopy
Sinusotomy
Stapedectomy
Tonsillectomy
Tracheostomy
Tympanoplasty
Ophthalmologic
Scleral Buckle
Vitrectomy
PLASTIC*
Rarely Some Experience Proficient Trainer / Preceptor N/A
Abdominal Lipectomy
Free Flaps
PLASTIC - MAMMOPLASTY*
Rarely Some Experience Proficient Trainer / Preceptor N/A
Augmentation
Reduction
TRAM Flap
Mentoplasty
Otoplasty
Scar Revisions
Split Thickness Skin Grafting
Tissue Expanders
TRANSPLANT*
Rarely Some Experience Proficient Trainer / Preceptor N/A
Bone
Bone Marrow
Corneal
Heart
Kidney
Liver
Lung
Pancreas
Harvesting
TRAUMA*
Rarely Some Experience Proficient Trainer / Preceptor N/A
Burns
Gunshot/Stab Wounds

Skills / Procedures*

	Rarely	Some Experience	Proficient	Trainer / Preceptor	N/A
Blood/Blood Product Infusion
Foley Catheter Insertion & Care
Intubation
Extubation
Intravenous Therapy
Malignant Hyperthermia Crisis
Oxygen Therapy Administration
Suctioning
Temperature
Wound Care

EQUIPMENT & SUPPLIES*
Rarely Some Experience Proficient Trainer / Preceptor N/A
Autoclave
Bair Hugger
Blood/Fluid Warmer
Camera/Video Systems
Dermatome
Drills
Fracture Tables
Laser
Infusion Delivery Devices (specify)
Infusion Device #1
Infusion Device #2
Infusion Device #3
PAIN MANAGEMENT*
Rarely Some Experience Proficient Trainer / Preceptor N/A
Pain Level Assessment
PAIN MANAGEMENT - CARE OF PATIENT WITH*
Rarely Some Experience Proficient Trainer / Preceptor N/A
Epidural Anesthesia
IV Conscious Sedation
PCA
Narcotic Agents
INFUSION DELIVERY DEVICE EXPERIENCE
Rarely Some Experience Proficient Trainer / Preceptor N/A
Infusion Device #1
Infusion Device #2
Infusion Device #3
PRIMARY OR EXPERIENCE (# OF YEARS)
Endoscopy
Cardiothoracic
General Surgery
Gynecologic
Neurosurgical
Ophthalmologic
Oral
Orthopedic
Otorhinolaryngologic
Plastic
Transplant
Trauma
Urologic
Vascular
Do you speak any languages other than English?*
- No
If yes, enter languages above, separated by commas.

Age Group Experience*

Confirmation*
- I attest that the information I have given is both true and, to the best of my knowledge, represents an accurate self assessment of my professional skills and/or education.
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Date
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Skills Checklist – Operating Room

	Rarely	Some Experience	Proficient	Trainer / Preceptor	N/A
CABG
Chest Tube Insertion
Closed Thoracotomy
Coarctation Resection, Aorta

	Rarely	Some Experience	Proficient	Trainer / Preceptor	N/A
Closed Reduction Facial Fractures
Excision Odontoma
Fractured Jaws

	Rarely	Some Experience	Proficient	Trainer / Preceptor	N/A
Adenoidectomy
Cleft Lip/Palate Repair
Closed Reduction Nasal Fracture
Laryngectomy
Open Reduction
Facial Fractures
Nasal Fractures
Radical Neck Dissection