perioperative skills checklist - msg ‐oophorectomy tubal ligation vaginal hysterectomy...

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  • 51UnionSt,Suite105,Worcester,MA01608.(T):1888MSGRNRN(6747676),5087997674(F):18882016674,15087996674

    PERIOPERATIVESKILLSCHECKLIST

    _____________________Date:

    FullName:

    INSTRUCTIONS

    Pleaseprovideaccurateanswerssowecancorrectlymatchyourabilitiestoourclientjobrequirements.Pleasecheckthelevelofexperienceandexpertiseyouhaveineachskillcategory,usingthefollowingscale:

    #1=Familiarwithprocedurebutwillusuallyoralmostalwaysrequiresomeassistance.

    #2=Competent andfamiliarwithprocedure:Icanperformthisprocedurewithexcellence,usuallywithoutassistance.

    #3=Verycompetent:Ihaveatleast12monthsexperienceandcanperformthisprocedurewithexcellenceandwithoutassistance.

    NOTE:Leaveblankanyprocedureswhichyouhavenoexperience,trainingorlowcompetence.

    Scrub CirculateSKILLS: 1 2 3 1 2 3Ear,Nose&ThroatAdenoidectomy CaldwellLuc Cleftlip/palaterepair Closedreductionnasalfracture

    Ethmoidectomy Excisionofsalivaryglandtumor

    Fenestrationprocedure Frontalflapsinusprocedure

    Glossectomy Laryngectomy Mandibulectomy Mastoidectomy Maxillaryadvancementw/hipgraft

    Maxillectomy Myringoplasty Myringotomyw/PEtubeinsertion

    Nasalpolypectomy Openreductionfacialfracture

    Openreductionnasalfracture

    Parotidectomy Pharyngealflapprocedure Radicalneckdissection Ranulectomy Rhinoplasty/septoplasty

    Scrub CirculateSKILLS: 1 2 3 1 2 3Selectiveosteotomyofmaxilla/mandible

    Sinusendoscopy Sinusotmy Stapedectomy Submucousresection Tonsillectomy Tracheostomy Tympanoplasty EndoscopicProceduresBronchoscopy Colonoscopy Culdoscopy Cystoscopy Esophagoscopy Gastroscopy Hysteroscopy Laparoscopicprocedures:Appendectomy Cholecystecomy/choloangiogram

    Colonresection Herniarepair Nissenfundoplication Salpingo oophorectomy Tuballigation Vaginalhysterectomy Laryngoscopy&microlaryngoscopy:Mediastinoscopy Pelviscopy Sigmoidoscopy Thorascopy

  • 2

    51UnionSt,Suite105,Worcester,MA01608.(T):1888MSGRNRN(6747676),5087997674(F):18882016674,15087996674

    Scrub CirculateSKILLS: 1 2 3 1 2 3GeneralSurgeryAbdominalperinealresection

    Adrenalectomy Analfissurectomy Appendectomy Breastbiopsy Colectomy Colostomy/ileostomy Gastrectomy Gastroplasty Hemorrhoidectomy Hepaticresection Herniorrhapyfemoral,inguinal,umbilical

    Hiatalherniorrhaphytransabdominal/transthoracic

    Hickman/Groshong/Portachinsertion

    Hydrocelectomy Imperforateanusreconstruction

    Lumbarsympahtectomy Ornpahlocelerepair Pancreatectomy/pancreatogram

    Pilonidalcystectomy Portalcavalshunt Pyloricstenosis Radicalmastectomy Splenectomy Tenchkhoffcatheterplacement

    Thyroglossalductcystexcision

    Thyroidectomy Tracheostomy Vagotomy GynecologyCesareansection Colpotomy Dialtion&curettage(D&C) Hysterectomy,abdominal Hysterectomy,vaginal MarshallMarchetti Marupialization,BartholinCyst

    Ovariancystectomy Radiuminsertion Sacralspinusfixation Shirodkarprocedure

    Scrub CirculateSKILLS: 1 2 3 1 2 3Suctioncurettage Vaginalreconstruction Vaginectomy/vulvectomy NeurologyAVmalformation Anteriorcervicalfusion Anteriorlaparoscopicspineprocedures

    Anteriorlumbarinterbodyfusion(ALIF)

    Burrholesforsubduralhematoma

    Carotidligation Cervicalsympathectomy Craniectomyfordecompressionfracture

    Cranioplasty/craniotomy:Clippingofaneurysm Tumorexcision Usingstealthequipment(stealthcraniotomy)

    Discectomy Hypophysectomy Insertionnervestimulators/medicationpumps

    Laminectomy Myelomeningocelerepair Pediclescrewinsertion Posteriorlumbarinterbodyfusion(PLIF)

    Shuntprocedure/VP,VA/LP Spinefusion listsystemsyouhaveused

    Ulnarnervetransfer Ventriculographyprocedure/ventriculoscopy

    Ventriculostomy OpthalmologyCataractextractionwithIOL Cornealtransplant Dacryocystectomy Dacryocystorhinostomy Iridectomy Lid&muscleprocedures Orbitalimplant Phacoemulsification Pterygiumrepair Recessionresection Repairorbitalblowoutfracture

    Sceleralbuckle Vitrectomy

  • 3

    51UnionSt,Suite105,Worcester,MA01608.(T):1888MSGRNRN(6747676),5087997674(F):18882016674,15087996674

    Scrub CirculateSKILLS: 1 2 3 1 2 3OralClosedreductionfacialfractures/wiring

    Excisionodontoma Extractionofdeciduousteeth Extractionofimpactedmolars Fracturedjaws,mandibularandzagomatic

    LeFortosteotomies Maxillaryprocedurewithgraft

    Pediatricdentistry Sagittalosteotomy Temporomandibularjoint(TMJ)witharthroplasty

    TMJexploration OrthopedicAcetabular/pelvicORIF Achillestendonrepair Amputationleg,arm Anteriorcruciateligamentrepair

    Applicationofexternalfixators:Extremities Pelvis

    Applicationofhalotraction Arthroscopy:Ankle Elbow Knee Shoulder

    Arthroscopy Bipolar/unipolarhips Bunionectomy Calcanealreconstruction Capsulorrhaphy Carpaltunnelrelease Closedreductionfracture Handsurgerywithimplants

    Harringtonrodinstrumentation&/orDwyerprocedure

    Heelcordlengthening Hipcompressionnails&lagscrews:Jewett Kuntscherrod Lottes Rush Schneider Zimmer Others(pleaselistbelow:)

    Scrub CirculateSKILLS: 1 2 3 1 2 3Laminectomy Olecranonbursa,excisionof Openreductionoffracture,internalfixationwithcompressionset

    Patellectomy PuttPlatt/Bankartprocedure/rotatorcuffrepair

    Reductionw/compressionsets Reimplantationofdigits Repairhammertoes Sacroilia(SI)jointscrews Sharradprocedure Spicacast,applicationof Spinalfusion Tendontransplants(hand&foot)

    Totaljointreplacement/revisions:Totalhip Totalknee Totalshoulder

    PlasticsAbdominallipectomy Blepharoplasty Facelift Mammoplasty:Augmentation Reduction Tramflapsw/reconstructivemammoplasty

    Mentoplasty Otoplasty Pediclegrafts Scarrevisions Splitthicknessskingrafting Tissueexpanders Thoracic&OpenHeartCervicalribexcision Chamberlainprocedure Closedthoractomy Correctionpectusexcavatum Esophagectomy Hellerprocedure Mitralcommissurotomy Openheartprocedures:Mitraloraorticvalvereplacement

    Patentductusarteriosus Septaldefectrepairs TetrologyofFallot

  • 4

    51UnionSt,Suite105,Worcester,MA01608.(T):1888MSGRNRN(6747676),5087997674(F):18882016674,15087996674

    Scrub CirculateSKILLS: 1 2 3 1 2 3Pacemakerimplantationendocardial

    Pericardiectomy Resectioncoarctationaorta

    Ribresection Thoracoplasty Trachealresection Transthoracicdiaphragmaticherniorrhapahy

    TransplantBone Bonemarrow Corneal Harvesting Heart Kidney Liver Lung Multiorgan Pancreas Skin TraumaBurns Gunshot/stabwounds:Abdomen Chest Head

    Motorvehicleaccidents(multipleinjuries)

    Traumaticamputations UrologyAdultcircumcision Cystectomy

    Scrub CirculateSKILLS: 1 2 3 1 2 3Cystoscopy/ureteroscopy Hypospadiasrepair Implants;penile,testicular Lithotripsy Nephrectomy Nephrolithotomy Orchiopexy Prostatectomy:Perineal Suprapubic Pyeloplasty Radicalnodedissection Scottincontinencedevice TURP Ureterolithotomy Vasectomy Vasovasostomy Waterhouseprocedure

    VascularAVaccessgraft Aorticaneurysmw/graftreplacement

    Endarterectomy/carotidfemoral

    Peripheralvascularbypassprocedures

    Resectioncarotidaneurysmw/graft

    Thrombectomy/embolectomy

    Venacavafilter/umbrella Venacavalitigation

    CirculateSKILLS: 1 2 3AnesthesiaAssistw/intubation Conscioussedationadministration&monitoring

    Managementofmalignanthyperthermiacrisis

    EquipmentArgonbeamcoagulator BairHugger Blood/fluidwarmer

    CirculateSKILLS: 1 2 3

    Camera/videosystem:CameracontrollerLightsourcePrintersVCRs

    Cardiacmonitor&pacemakerCellsaverCidexsoakCryophthalmicunitDebrillator/pacer

  • 5

    51UnionSt,Suite105,Worcester,MA01608.(T):1888MSGRNRN(6747676),5087997674(F):18882016674,15087996674

    CirculateSKILLS: 1 2 3Dermatome:Brown Padgett Zimmer

    Disposablegroundingpads Drills:3MMaxidriver Codmancraniotome Hallairdriver Halldental Hallneurotone MidaxRex/Anspach Minidriver Strykerdrills (1)LargebatteryStryker (2)SmallbetteryStryker Surgairtone SynthesA0Drill Electrosurgicalunit Emersonthoracpump EthyleneoxidesterilizerAMSCO Emersonthoracicpump EyeMagnet Fiberopticluminatorlisttypes FlashautoclaveAMSCO

    Fracturetables:Chicktable/Marquettable Jacksontable Rushtable/Skytrontable

    Hypo/hyperthermiaunit Intestinalstaplingdevices:EEA GIA LDS TA

    Kreiselmanresuscitator Laser:CO2 Eye Yag Other(pleaselist)

    Meshgraft Microscopes,listtype Nervestimulator Nitrousoxidebank Ohiosuctionunits Orthopedicarmboardw/drain Pleurevacdisposablechestdrainage

    CirculateSKILLS: 1 2 3PneumatictourniquetSteradmachineSterivacaerationcabinet,3M,portable

    SterisunitSuctionunit,disposableTelethermometerUltrasoniccleaner AMSCOVacpacpositionerVacuumcurettageWashersanitizer AMSCOWashersterilizer AMSCOPhlebotomy/IVTherapyEquipment&proceduresAdministrationofblood/bloodproducts:PackedredbloodcellWholeblood

    Assistw/IA/IVtherapy:InsertionofAlinesInsertionofCVPjugular/subclavian

    InsertionofSwanGanzDrawingbloodfromcentrallineDrawingvenousbloodStartingIVs:Angiocath

    AgeSpecificPracticeCriteriaNewborn/Neonate(birth30days)Infant(30days 1yr)Toddler(1 3yrs)Preschooler(3 5yrs)Schoolagechildren(5 12yrs)Adolescents(1218yrs)YoungAdults(1839yrs)MiddleAdults(39 64yrs)OlderAdults(64+yrs)Careofpatientwith:Abletoadaptcaretoincorporatenormalgrowthanddevelopment.Abletoadaptmethodandterminologyofpatientinstructionstotheirage,comprehensionandmaturitylevel.Canensureasafeenvironmentreflectingspecificneedsofvariousgroups.Myexperienceisprimarilyin:Traumareferralcenter(LevelIER)CommunityER(LevelIIER)Rur

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