Perioperative Skills Checklist         

* Denotes required field
This profile is for use by Perioperative nurses with more than one year experience in their discipline and specialty. It will not be a determining factor for employment but it may aid in promoting yourself at the Interview.

Please enter your full legal name as it appears on your Social Security Card.


First name*

____________________________________
Last name*

___________________________

Social Security number

______- ______ -  ______

 Date

______ / ______ / ______

 

Email:  _________________________________________
Please indicate your level of experience by checking the applicable box.
A. Theory, no practice C. Two-plus years experience
B. One - two years experience  

A. EAR, NOSE & THROAT SCRUB CIRCULATE
  1. Adenoidectomy | A |     | B |     | C | | A |     | B |     | C |
  2. Caldwell - Luc | A |     | B |     | C | | A |     | B |     | C |
  3. Cleft lip/palate repair | A |     | B |     | C | | A |     | B |     | C |
  4. Closed reduction nasal fracture | A |     | B |     | C | | A |     | B |     | C |
  5. Ethmoidectomy | A |     | B |     | C | | A |     | B |     | C |
  6. Excision of salivary gland tumor | A |     | B |     | C | | A |     | B |     | C |
  7. Fenestration procedure | A |     | B |     | C | | A |     | B |     | C |
  8. Frontal flap sinus procedure | A |     | B |     | C | | A |     | B |     | C |
  9. Glossectomy | A |     | B |     | C | | A |     | B |     | C |
  10. Laryngectomy | A |     | B |     | C | | A |     | B |     | C |
  11. Mandibulectomy | A |     | B |     | C | | A |     | B |     | C |
  12. Mastoidectomy | A |     | B |     | C | | A |     | B |     | C |
  13. Maxillary advancement with hip graft | A |     | B |     | C | | A |     | B |     | C |
  14. Maxillectomy | A |     | B |     | C | | A |     | B |     | C |
  15. Myringoplasty | A |     | B |     | C | | A |     | B |     | C |
  16. Myringotomy/with PE tube insertion | A |     | B |     | C | | A |     | B |     | C |
  17. Nasal polypectomy | A |     | B |     | C | | A |     | B |     | C |
  18. Open reduction facial fracture | A |     | B |     | C | | A |     | B |     | C |
  19. Open reduction nasal fracture | A |     | B |     | C | | A |     | B |     | C |
  20. Parotidectomy | A |     | B |     | C | | A |     | B |     | C |
  21. Pharyngeal flap procedure | A |     | B |     | C | | A |     | B |     | C |
  22. Radical neck dissection | A |     | B |     | C | | A |     | B |     | C |
  23. Ranulectomy | A |     | B |     | C | | A |     | B |     | C |
  24. Rhinoplasty/septoplasty | A |     | B |     | C | | A |     | B |     | C |
  25.Selective osteotomy of maxilla/mandible | A |     | B |     | C | | A |     | B |     | C |
  26. Sinus endoscopy | A |     | B |     | C | | A |     | B |     | C |
  27. Sinusotomy | A |     | B |     | C | | A |     | B |     | C |
  28. Stapedectomy | A |     | B |     | C | | A |     | B |     | C |
  29. Submucous resection | A |     | B |     | C | | A |     | B |     | C |
  30. Tonsillectomy | A |     | B |     | C | | A |     | B |     | C |
  31. Tracheostomy | A |     | B |     | C | | A |     | B |     | C |
  32. Tympanoplasty | A |     | B |     | C | | A |     | B |     | C |

B. ENDOSCOPIC PROCEDURES SCRUB CIRCULATE
  1. Bronchoscopy | A |     | B |     | C | | A |     | B |     | C |
  2. Colonoscopy | A |     | B |     | C | | A |     | B |     | C |
  3. Culdoscopy | A |     | B |     | C | | A |     | B |     | C |
  4. Cystoscopy | A |     | B |     | C | | A |     | B |     | C |
  5. Esophagoscopy | A |     | B |     | C | | A |     | B |     | C |
  6. Gastroscopy | A |     | B |     | C | | A |     | B |     | C |
  7. Hysteroscopy | A |     | B |     | C | | A |     | B |     | C |
  8. Laparoscopic procedures    
    a. Appendectomy | A |     | B |     | C | | A |     | B |     | C |
    b. Cholecystectomy/cholangiogram | A |     | B |     | C | | A |     | B |     | C |
    c. Colon resection | A |     | B |     | C | | A |     | B |     | C |
    d. Hernia repair | A |     | B |     | C | | A |     | B |     | C |
    e. Nissen fundoplication | A |     | B |     | C | | A |     | B |     | C |
    f. Salpingo-oophorectomy | A |     | B |     | C | | A |     | B |     | C |
    g. Tubal ligation | A |     | B |     | C | | A |     | B |     | C |
    h. Vaginal hysterectomy | A |     | B |     | C | | A |     | B |     | C |
  9. Laryngoscopy & microlaryngoscopy | A |     | B |     | C | | A |     | B |     | C |
  10. Mediastinoscopy | A |     | B |     | C | | A |     | B |     | C |
  11. Pelviscopy | A |     | B |     | C | | A |     | B |     | C |
  12. Sigmoidoscopy | A |     | B |     | C | | A |     | B |     | C |
  13. Thoracoscopy | A |     | B |     | C | | A |     | B |     | C |

C. GENERAL SURGERY SCRUB CIRCULATE
  1. Abdominal perineal resection | A |     | B |     | C | | A |     | B |     | C |
  2. Adrenalectomy | A |     | B |     | C | | A |     | B |     | C |
  3. Anal fissurectomy | A |     | B |     | C | | A |     | B |     | C |
  4. Appendectomy | A |     | B |     | C | | A |     | B |     | C |
  5. Breast biopsy | A |     | B |     | C | | A |     | B |     | C |
  6. Colectomy | A |     | B |     | C | | A |     | B |     | C |
  7. Colostomy/ileostomy | A |     | B |     | C | | A |     | B |     | C |
  8. Gastrectomy | A |     | B |     | C | | A |     | B |     | C |
  9. Gastroplasty | A |     | B |     | C | | A |     | B |     | C |
  10. Hemorrhoidectomy | A |     | B |     | C | | A |     | B |     | C |
  11. Hepatic resection | A |     | B |     | C | | A |     | B |     | C |
  12. Herniorrhaphy - femoral, inguinal, umbilical | A |     | B |     | C | | A |     | B |     | C |
  13. Hiatal herniorrhaphy, transabdominal/transthoracic | A |     | B |     | C | | A |     | B |     | C |
  14. Hickman/Groshong/Portacath insertion | A |     | B |     | C | | A |     | B |     | C |
  15. Hydrocelectomy | A |     | B |     | C | | A |     | B |     | C |
  16. Imperforate anus reconstruction | A |     | B |     | C | | A |     | B |     | C |
  17. Lumbar sympathectomy | A |     | B |     | C | | A |     | B |     | C |
  18. Omphalocele repair | A |     | B |     | C | | A |     | B |     | C |
  19. Pancreatectomy/pancreatogram | A |     | B |     | C | | A |     | B |     | C |
  20. Pilonidal cystectomy | A |     | B |     | C | | A |     | B |     | C |
  21. Portal caval shunt | A |     | B |     | C | | A |     | B |     | C |
  22. Pyloric stenosis | A |     | B |     | C | | A |     | B |     | C |
  23. Radical mastectomy | A |     | B |     | C | | A |     | B |     | C |
  24. Saphenous vein ligation and stripping | A |     | B |     | C | | A |     | B |     | C |
  25. Sentinel node biopsy | A |     | B |     | C | | A |     | B |     | C |
  26. Splenectomy | A |     | B |     | C | | A |     | B |     | C |
  27. Tenchkhoff catheter placement | A |     | B |     | C | | A |     | B |     | C |
  28. Thyroglossal duct cyst excision | A |     | B |     | C | | A |     | B |     | C |
  29. Thyroidectomy | A |     | B |     | C | | A |     | B |     | C |
  30. Tracheostomy | A |     | B |     | C | | A |     | B |     | C |
  31. Vagotomy  A |     | B |     | C | | A |     | B |     | C |

D. GYNECOLOGY SCRUB CIRCULATE
  1. Cesarean section | A |     | B |     | C | | A |     | B |     | C |
  2. Colpotomy | A |     | B |     | C | | A |     | B |     | C |
  3. Dilation and curettage (D & C) | A |     | B |     | C | | A |     | B |     | C |
  4. Hysterectomy, abdominal | A |     | B |     | C | | A |     | B |     | C |
  5. Hysterectomy, vaginal | A |     | B |     | C | | A |     | B |     | C |
  6. Marshall - Marchetti | A |     | B |     | C | | A |     | B |     | C |
  7. Marsupialization, Bartholin cyst | A |     | B |     | C | | A |     | B |     | C |
  8. Ovarian cystectomy | A |     | B |     | C | | A |     | B |     | C |
  9. Radium insertion | A |     | B |     | C | | A |     | B |     | C |
  10. Sacral spinus fixation | A |     | B |     | C | | A |     | B |     | C |
  11. Shirodkar procedure | A |     | B |     | C | | A |     | B |     | C |
  12. Suction curettage | A |     | B |     | C | | A |     | B |     | C |
  13. Vaginal reconstruction | A |     | B |     | C | | A |     | B |     | C |
  14. Vaginectomy/vulvectomy | A |     | B |     | C | | A |     | B |     | C |

E. NEUROLOGY SCRUB CIRCULATE
  1. A-V malformation | A |     | B |     | C | | A |     | B |     | C |
  2. Anterior cervical fusion | A |     | B |     | C | | A |     | B |     | C |
  3. Anterior laparoscopic spine procedures | A |     | B |     | C | | A |     | B |     | C |
  4. Anterior lumbar interbody fusion (ALIF) | A |     | B |     | C | | A |     | B |     | C |
  5. Burr holes for subdural hematoma | A |     | B |     | C | | A |     | B |     | C |
  6. Carotid ligation | A |     | B |     | C | | A |     | B |     | C |
  7. Cervical sympathectomy | A |     | B |     | C | | A |     | B |     | C |
  8. Craniectomy for decompression fracture | A |     | B |     | C | | A |     | B |     | C |
  9. Cranioplasty/craniotomy    
    a. Clipping of aneurysm | A |     | B |     | C | | A |     | B |     | C |
    b. Tumor excision | A |     | B |     | C | | A |     | B |     | C |
    c. Using stealth equipment (stealth craniotomy) | A |     | B |     | C | | A |     | B |     | C |
  10. Discectomy | A |     | B |     | C | | A |     | B |     | C |
  11. Hypophysectomy | A |     | B |     | C | | A |     | B |     | C |
  12. Insertion nerve stimulators/medication pumps | A |     | B |     | C | | A |     | B |     | C |
  13. Laminectomy | A |     | B |     | C | | A |     | B |     | C |
  14. Myelomeningocele repair | A |     | B |     | C | | A |     | B |     | C |
  15. Pedicle screw insertion | A |     | B |     | C | | A |     | B |     | C |
  16. Posterior lumbar interbody fusion (PLIF) | A |     | B |     | C | | A |     | B |     | C |
  17. Shunt procedure/VP, VA/LP | A |     | B |     | C | | A |     | B |     | C |
  18. Spine fusion - list systems you have used Enter:____________  _____________
  19. Ulnar nerve transfer | A |     | B |     | C | | A |     | B |     | C |
  20. Ventriculography procedure/ventriculoscopy | A |     | B |     | C | | A |     | B |     | C |
  21. Ventriculostomy | A |     | B |     | C | | A |     | B |     | C |

F. OPHTHALMOLOGY SCRUB CIRCULATE
  1. Cataract extraction with IOL | A |     | B |     | C | | A |     | B |     | C |
  2. Corneal transplant | A |     | B |     | C | | A |     | B |     | C |
  3. Dacryocystectomy | A |     | B |     | C | | A |     | B |     | C |
  4. Dacryocystorhinostomy | A |     | B |     | C | | A |     | B |     | C |
  5. Iridectomy | A |     | B |     | C | | A |     | B |     | C |
  6. Lid and muscle procedures | A |     | B |     | C | | A |     | B |     | C |
  7. Orbital implant | A |     | B |     | C | | A |     | B |     | C |
  8. Phaco emulsification | A |     | B |     | C | | A |     | B |     | C |
  9. Pterygium repair | A |     | B |     | C | | A |     | B |     | C |
  10. Recession resection | A |     | B |     | C | | A |     | B |     | C |
  11. Repair orbital blowout fracture | A |     | B |     | C | | A |     | B |     | C |
  12. Scleral buckle | A |     | B |     | C | | A |     | B |     | C |
  13. Vitrectomy | A |     | B |     | C | | A |     | B |     | C |

G. ORAL SCRUB CIRCULATE
  1. Closed reduction facial fractures/wiring | A |     | B |     | C | | A |     | B |     | C |
  2. Excision odontoma | A |     | B |     | C | | A |     | B |     | C |
  3. Extraction of deciduous teeth | A |     | B |     | C | | A |     | B |     | C |
  4. Extraction of impacted molars | A |     | B |     | C | | A |     | B |     | C |
  5. Fractured jaws, mandibular and zagomatic | A |     | B |     | C | | A |     | B |     | C |
  6. LeFort osteotomies | A |     | B |     | C | | A |     | B |     | C |
  7. Maxillary procedure with graft | A |     | B |     | C | | A |     | B |     | C |
  8. Pediatric dentistry | A |     | B |     | C | | A |     | B |     | C |
  9. Sagittal osteotomy | A |     | B |     | C | | A |     | B |     | C |
  10. Temporomandibular joint (TMJ) with arthroplasty | A |     | B |     | C | | A |     | B |     | C |
  11. TMJ exploration | A |     | B |     | C | | A |     | B |     | C |

H. ORTHOPEDICS SCRUB CIRCULATE
  1. Acetabular/pelvic ORIF | A |     | B |     | C | | A |     | B |     | C |
  2. Achilles tendon repair | A |     | B |     | C | | A |     | B |     | C |
  3. Amputation - leg, arm | A |     | B |     | C | | A |     | B |     | C |
  4. Anterior cruciate ligament repair | A |     | B |     | C | | A |     | B |     | C |
  5. Application of external fixators    
    a. Extremities | A |     | B |     | C | | A |     | B |     | C |
    b. Pelvis | A |     | B |     | C | | A |     | B |     | C |
  6. Application of halo traction | A |     | B |     | C | | A |     | B |     | C |
  7. Arthroscopy    
    a. Ankle | A |     | B |     | C | | A |     | B |     | C |
    b. Elbow | A |     | B |     | C | | A |     | B |     | C |
    c. Knee | A |     | B |     | C | | A |     | B |     | C |
    d. Shoulder | A |     | B |     | C | | A |     | B |     | C |
  8. Arthrotomy | A |     | B |     | C | | A |     | B |     | C |
  9. Bipolar/unipolar hips | A |     | B |     | C | | A |     | B |     | C |
  10. Bunionectomy | A |     | B |     | C | | A |     | B |     | C |
  11. Calcaneal reconstruction | A |     | B |     | C | | A |     | B |     | C |
  12. Capsulorrhaphy | A |     | B |     | C | | A |     | B |     | C |
  13. Carpal tunnel release | A |     | B |     | C | | A |     | B |     | C |
  14. Closed reduction fracture | A |     | B |     | C | | A |     | B |     | C |
  15. Hand surgery with implants | A |     | B |     | C | | A |     | B |     | C |
  16. Harrington rod instrumentation and/or Dwyer procedure | A |     | B |     | C | | A |     | B |     | C |
  17. Heel cord lengthening | A |     | B |     | C | | A |     | B |     | C |
  18. Hip compression nails & lag screws
    a. Jewett | A |     | B |     | C | | A |     | B |     | C |
    b. Kuntscher rod | A |     | B |     | C | | A |     | B |     | C |
    c. Lottes | A |     | B |     | C | | A |     | B |     | C |
    d. Rush | A |     | B |     | C | | A |     | B |     | C |
    e. Schneider | A |     | B |     | C | | A |     | B |     | C |
    f. Zimmer | A |     | B |     | C | | A |     | B |     | C |
    g. Others - list Enter:__________  ____________
  19. Iliac crest bone graft | A |     | B |     | C | | A |     | B |     | C |
  20. Insertion Austin Moor hip prosthesis | A |     | B |     | C | | A |     | B |     | C |
  21. Intramedullary rods    
    a. Extraction | A |     | B |     | C | | A |     | B |     | C |
    b. Femoral | A |     | B |     | C | | A |     | B |     | C |
    c. Humeral | A |     | B |     | C | | A |     | B |     | C |
    d. Insertion | A |     | B |     | C | | A |     | B |     | C |
    e. Supracondylar | A |     | B |     | C | | A |     | B |     | C |
    f. Tibial | A |     | B |     | C | | A |     | B |     | C |
  22. Laminectomy | A |     | B |     | C | | A |     | B |     | C |
  23. Olecranon bursa, excision of | A |     | B |     | C | | A |     | B |     | C |
  24. Open reduction of fracture, internal fixation with compression set | A |     | B |     | C | | A |     | B |     | C |
  25. Patellectomy | A |     | B |     | C | | A |     | B |     | C |
  26. Putti Platt/Bankart procedure/rotator cuff repair | A |     | B |     | C | | A |     | B |     | C |
  27. Reduction with compression sets | A |     | B |     | C | | A |     | B |     | C |
  28. Reimplantation of digits | A |     | B |     | C | | A |     | B |     | C |
  29. Repair hammer toes | A |     | B |     | C | | A |     | B |     | C |
  30. Sacro-iliac (SI) joint screws | A |     | B |     | C | | A |     | B |     | C |
  31. Sharrard procedure | A |     | B |     | C | | A |     | B |     | C |
  32. Spica cast, application of | A |     | B |     | C | | A |     | B |     | C |
  33. Spinal fusion | A |     | B |     | C | | A |     | B |     | C |
  34. Tendon transplants (hand and foot) | A |     | B |     | C | | A |     | B |     | C |
  35. Total joint replacements/revisions
    a. Total hip | A |     | B |     | C | | A |     | B |     | C |
    b. Total knee | A |     | B |     | C | | A |     | B |     | C |
    c. Total shoulder | A |     | B |     | C | | A |     | B |     | C |

I. PLASTICS SCRUB CIRCULATE
  1. Abdominal lipectomy | A |     | B |     | C | | A |     | B |     | C |
  2. Blepharoplasty | A |     | B |     | C | | A |     | B |     | C |
  3. Face lift | A |     | B |     | C | | A |     | B |     | C |
  4. Mammoplasty
    a. Augmentation | A |     | B |     | C | | A |     | B |     | C |
    b. Reduction | A |     | B |     | C | | A |     | B |     | C |
    c. Tramflaps with reconstructive mammoplasty | A |     | B |     | C | | A |     | B |     | C |
  5. Mentoplasty | A |     | B |     | C | | A |     | B |     | C |
  6. Otoplasty | A |     | B |     | C | | A |     | B |     | C |
  7. Pedicle grafts | A |     | B |     | C | | A |     | B |     | C |
  8. Scar revisions | A |     | B |     | C | | A |     | B |     | C |
  9. Split thickness skin grafting | A |     | B |     | C | | A |     | B |     | C |
  10. Tissue expanders | A |     | B |     | C | | A |     | B |     | C |

J. THORACIC & OPEN HEART SCRUB CIRCULATE
  1. Cervical rib excision | A |     | B |     | C | | A |     | B |     | C |
  2. Chamberlain procedure | A |     | B |     | C | | A |     | B |     | C |
  3. Closed thoracotomy | A |     | B |     | C | | A |     | B |     | C |
  4. Correction pectus excavatum | A |     | B |     | C | | A |     | B |     | C |
  5. Esophagectomy | A |     | B |     | C | | A |     | B |     | C |
  6. Heller procedure | A |     | B |     | C | | A |     | B |     | C |
  7. Mitral commissurotomy | A |     | B |     | C | | A |     | B |     | C |
  8. Open heart procedures
    a. Mitral or aortic valve replacement | A |     | B |     | C | | A |     | B |     | C |
    b. Patent ductus arteriosus | A |     | B |     | C | | A |     | B |     | C |
    c. Septal defect repairs | A |     | B |     | C | | A |     | B |     | C |
    d. Tetrology of Fallot | A |     | B |     | C | | A |     | B |     | C |
  9. Pacemaker implantation-endocardial | A |     | B |     | C | | A |     | B |     | C |
  10. Pacemaker implantation-myocardial | A |     | B |     | C | | A |     | B |     | C |
  11. Pericardiectomy | A |     | B |     | C | | A |     | B |     | C |
  12. Resection coarctation aorta | A | &nbs