Road Trip Nursing
333 1st. St. North -- Suite 200
Jacksonville Beach, FL 32250
Fax:(888) 794-5038

  

OPERATING ROOM SKILLS CHECKLIST
First Name:
Last Name:
Phone:
Email:
SSN (last 4 only):
Date:
 
Key - for each box mark:   1 - Limited or no experience 2 - Somewhat experienced but may need review
    3 - Can function independently 4 - Competent to supervise

      Circulate       Scrub       Assist
Procedures 1     2     3     4   1     2     3     4   1     2     3     4
Cardiovascular          
    Aorto-Femoral Bypass, Graft Insertion    
    A-V Shunts    
    Aneurysms with Graft Replacement    
    Cardiac Valve Replacement    
    Coronary Artery Bypass Graft    
    Endarterectomy - Carotid/Femoral    
    External Temporary Pacemaker    
    Groshong/Hickman Vascular Catheter    
    Internal Pacemaker Insertion    
    Intra-Aortic Balloon Pump Catheter    
    Saphenous Vein Ligation and Stripping    
    Thrombectomy    
Dental/Oral-Facial          
    Arch Bars    
    Closed Reduction Facial Fractures/Wiring    
    Fractured Jaw, Mandibular and Zagomatic    
    Mandibular Osteotomy    
    Maxillary Procedure with Graft    
    TMJ with Arthoplasty    
Endoscopy          
    Bronchoscopy    
    Colonoscopy    
    Cytoscopy    
    Gastroscopy    
    Laryngoscope    
    Sigmoidoscopy    
    Thoracoscopy    
Ear/Nose/Throat          
    Antral Windows    
    Closed Reduction Facial/Nasal Fx    
    Ethmoidectomy    

 
 
      Circulate       Scrub       Assist
Ear/Nose/Throat continued 1     2     3     4   1     2     3     4   1     2     3     4
    Laryngectomy    
    Mandibulectomy    
    Mastoidectomy    
    Nasal Polypectomy    
    Open Reduction Facial/Nasal Fx    
    Radical Neck Dissection    
    Septoplasty/Rhinoplasty    
    Tracheostomy    
    Tympanoplasty    
Eye          
    Cataract Extraction    
    Corneal Transplant    
    Enucleation    
    Fenestration Procedure    
    Lacrimal Duct Probing    
    Orbital Implant    
    Repair of Retinal Detachment    
General          
    Abdominal Perineal Resection    
    Bowel Resection    
    Cholecystectomy    
    Colostomy/Ileostomy    
    Gastrectomy    
    Herniorrhaphy-Feneral/Inguinal    
    Hiatal Herniorrhaphy Transabdominal    
    Pilonidal Cystectomy    
    Organ Procurement    
    Radical Mastectomy    
    Sentinel Node Biopsy    
    Splenectomy    
    Thyroidectomy    
    Tracheostomy    
Genitourinary/Cystoscopy          
    Cystoscopy/Cystostomy    
    Lithotripsy    
    Nephrectomy    
    Penile Implant    
    Prostatectomy    
    TURP/TURB    
    Ureterolithotomy    
    Vasectomy    

 
 
      Circulate       Scrub       Assist
Gynecology          
    Caesarean Section    
    Dilation and Curettage    
    Hysterectomy - Abdominal    
    Hysterectomy - Vaginal    
    Ovarian Cystectomy    
    Radium Implant    
    Salpingo-Oophorectomy    
    Suction Curettage    
    Termination of Pregnancy    
    Tubal Ligation    
    Vaginal Reconstruction    
Laparoscopy          
    Appendectomy    
    Cholecystectomy/Cholangiogram    
    Colon Resection    
    Hernia Repair    
    Salpingo-Oophorectomy    
    Tubal Ligation    
    Vaginal Hysterectomy    
Neurology          
    Cervical Fusion    
    Lumbar Interbody Fusion    
    Burr Holes for Subdural Hematoma    
    Carotid Ligation    
    Craniotoplasty/Craniotomy    
    Discectomy    
    Insertion Nerve Stimulators/Medication Pumps    
    Shunts          
      Lumbar Peritoneal    
      Ventricular Atrial    
      Ventricular Peritoneal    
Orthopedics          
    Acetabular/Pelvic ORIF    
    Amputation    
    Anterior Cruciate Ligament Repair    
    Application of External Fixators    
    Application of Halo Traction    
    Arthroscopy/Arthrotomy    
    Bunionectomy    
    Bursa    
    Carpal Tunnel Release    
    Closed Reduction Fracture    

 
 
      Circulate       Scrub       Assist
Orthopedics continued 1     2     3     4   1     2     3     4   1     2     3     4
    Hand Surgery    
    Iliac Crest Bone Graft    
    Hip Protheses    
    Intramedullary Rods    
    Laminectomy    
    Open Reduction of Fracture    
    Rotator Cuff Repair    
    Reduction with Compression Set    
    Reimplantation of Digits    
    Sacro-iliac Joint Screws    
    Spica Cast Application    
    Spinal Fusion    
    Tendon Transplants    
    Total Joint Replacements/Revisions    
Pediatric          
    Patent Ductus    
    Repair of Septal Defects    
    Coarctation of Aorta    
    Tetralogy of Fallot    
    Pacemaker    
    Cleft Lip/Palate Repair    
    Myringotomy with Tubes    
    Tonsillectomy/Adenoidectomy    
    Hypospadias Repair    
    Omphalocele Repair    
    Pyloric Stenosis    
    Myelomeningocele Repair    
    A-V Malformation    
    Harrington Rod Instrumentation/Dwyer Procedure    
    Resection of Coarctation Aorta    
Plastics          
    Abdominal Lipectomy/Abdominoplasty    
    Face Lift    
    Mammoplasty    
    Otoplasty    
    Rhinoplasty    
    Scar Revisions    
    Skin Grafts    
    Suction Lipectomy    
           

 
 
      Circulate       Scrub       Assist
Thoracic          
    Rib Excision    
    Closed Thoracotomy    
    Esophagectomy    
    Rib Resection    
    Thoracoplasty    
    Tracheal Resection    
    Transthoracic Diaphragmatic Herniorrhaphy    
Transplant          
    Bone    
    Bone Marrow    
    Corneal    
    Heart    
    Kidney    
    Liver    
    Lung    
    Multi-Organ    
    Pancreas    
    Skin    
Trauma          
    Burns    
    Gunshot/Stab Wounds    
    Motor Vehicle Accidents    
    Traumatic Amputations    
Equipment          
    Anspach Instruments    
    Aquamatic K Thermia Unit    
    Argon Beam Coagulator    
    Blood Warmer    
    Bovie Electrosurgical Unit    
    Cardiac Monitor and Pacemaker    
    Cell Saver    
    Dermatones    
    Disposable Bovie Plates    
    Drills    
    Dual Tract Lights    
    Ethylene Oxide Sterilizer    
    Fiber Optic Luminators    
    Flash Autoclave    
    Fracture Table    
    Pneumatic Tourniquet    
    Resuscitator    
    Laproscopic Equipment    

 
 
      Circulate       Scrub       Assist
Equipment continued 1     2     3     4   1     2     3     4   1     2     3     4
    Laser    
    Stapling Instruments    
    Suction Units    
    Operation Microscope    
    Set Synthes Compression    
    Aeration Cabinet    
    Ultrasonic Cleaner - AMSCO    
    Vac-Pac Positioner    
    Vacuum Curettage    
    Video Equipment    
    Washer Sterilizer - AMSCO    
Responsibilities          
Circulating Nurse          
  Assessment          
    Proper Identification and Documentation        
    Evaluation of Emotional Status        
    Identification of Physical Needs        
  Provision of Safe Environment          
    Proper Restraints        
    Adequate Temperature Control        
    Proper Positioning        
  Skin Preparation          
    Shave area        
    Select Proper Cleansing Agent        
    Perform Prep with Proper Aseptic Technique        
Scrub Nurse          
  Set Up          
    Distribute Packs, Tray, Equipment in Proper Order        
    Open All Sterile Packs Appropriately        
    Add Additional Supplies Aseptically        
    Gown and Glove Appropriately        
  Start Up          
    Draping Techniques    
    Knowledge of Suture Types and Applications    

The information I have provided in this skills checklist is true and accurate to the best of my knowledge. I hereby authorize PPR to release this information to client facilities of PPR in relation to consideration of my employment to those facilities
 



Submitting this form may take a few moments, please be patient. Thank you.
© 2004-2008 PPR