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Skills Assessment - Operating Room RN
 
The following checklist will be used to match your skills and interests with available assignments. Please enter your information, and we will store this information with your application/profile. Please indicate your level of proficiency by marking the appropriate number.
 
First Name:
Middle Initial:
Last Name:
SSN: - -
E-mail Address:
Home Phone: - -
Work Phone: - -
Cell Phone: - -
City:
State:
 
 
0. Theory, no practice   1. Limited   2. Confident   3. Very Confident
 
Scrub - Ear, Nose, & Throat: Experience:
Caldwell - Luc 0   1   2   3  
Laryngectomy 0   1   2   3  
Cleft lip/palate repair 0   1   2   3  
Radical neck dissection 0   1   2   3  
T&A 0   1   2   3  
 
Scrub - General Surgery:
Bronchoscopy 0   1   2   3  
Appendectomy 0   1   2   3  
Laparoscopic Appendectomy 0   1   2   3  
Cholecystectomy 0   1   2   3  
Laparoscopic Cholecystectomy 0   1   2   3  
Hernia Repair 0   1   2   3  
Laparoscopic Hernia Repair 0   1   2   3  
Colon Resection 0   1   2   3  
Rectal Surgery 0   1   2   3  
Pancreatectomy 0   1   2   3  
Splenectomy 0   1   2   3  
Thyroidectomy 0   1   2   3  
Vein Stripping 0   1   2   3  
Whipple Procedure 0   1   2   3  
Abdominal Perineal Resection 0   1   2   3  
 
Scrub - Gynecology:
Hysterectomy, abdominal 0   1   2   3  
Hysterectomy, vaginal 0   1   2   3  
Tubal ligation 0   1   2   3  
Tuboplasty 0   1   2   3  
Anterior posterior repair 0   1   2   3  
 
Scrub - Neurosurgery:
Craniotomy for Tumor 0   1   2   3  
Craniotomy for Aneurysm 0   1   2   3  
Ventricular Peritoneal Shunt 0   1   2   3  
Lumbar Laminectomy 0   1   2   3  
Cervical Laminectomy 0   1   2   3  
Posterior Sitting Laminectomy 0   1   2   3  
Transsphenoidal Hypophysectomy 0   1   2   3  
Ulnar Nerve Transposition 0   1   2   3  
 
Scrub - Opthalmology:
Cataract extraction with IOL 0   1   2   3  
Corneal transplant 0   1   2   3  
Scleral Buckling 0   1   2   3  
 
Scrub - Orthopedics:
Ankle Surgery 0   1   2   3  
Hand/Micro Hand Surgery 0   1   2   3  
Hip Prosthesis 0   1   2   3  
Knowles Pinning 0   1   2   3  
Spinal Fusion 0   1   2   3  
ACL Repair 0   1   2   3  
Shoulder Surgery 0   1   2   3  
Total Knee Surgery 0   1   2   3  
Total Hip Replacement 0   1   2   3  
ORIF 0   1   2   3  
 
Scrub - Plastics:
Liposuction 0   1   2   3  
Rhinoplasty 0   1   2   3  
Face Lift 0   1   2   3  
Skin Graft 0   1   2   3  
Breast Reconstruction 0   1   2   3  
Breast Reduction 0   1   2   3  
Cleft lip/palate repair 0   1   2   3  
Free/TRAM Flap 0   1   2   3  
 
Scrub - Thoracic & Open Heart:
Open Heart Bypass 0   1   2   3  
Open Heart Valve Replacement 0   1   2   3  
Aortic Aneurysm Repair 0   1   2   3  
Thoracotomy 0   1   2   3  
Lung Resection 0   1   2   3  
Pneumonectomy 0   1   2   3  
 
Scrub - Urology:
Cystectomy 0   1   2   3  
Kidney Transplant 0   1   2   3  
Percutaneous Nephrolithotomy 0   1   2   3  
Nephrectomy 0   1   2   3  
Prostatectomy 0   1   2   3  
TURP 0   1   2   3  
Ureterolithotomy 0   1   2   3  
Vasectomy 0   1   2   3  
 
Scrub - Vascular:
A-V access graft 0   1   2   3  
Carotid Endarterectomy 0   1   2   3  
Peripheral vascular bypass procedures 0   1   2   3  
Thrombectomy/embolectomy 0   1   2   3  
Vena cava filter/umbrella 0   1   2   3  
Vena cava ligation 0   1   2   3  
 
 
Circulate - Ear, Nose, & Throat: Experience:
Caldwell - Luc 0   1   2   3  
Laryngectomy 0   1   2   3  
Cleft lip/palate repair 0   1   2   3  
Radical neck dissection 0   1   2   3  
T & A 0   1   2   3  
 
Circulate - General Surgery:
Bronchoscopy 0   1   2   3  
Appendectomy 0   1   2   3  
Laparoscopic Appendectomy 0   1   2   3  
Cholecystectomy 0   1   2   3  
Laparoscopic Cholecystectomy 0   1   2   3  
Hernia Repair 0   1   2   3  
Laparoscopic Hernia Repair 0   1   2   3  
Colon Resection 0   1   2   3  
Rectal Surgery 0   1   2   3  
Pancreatectomy 0   1   2   3  
Splenectomy 0   1   2   3  
Thyroidectomy 0   1   2   3  
Vein Stripping 0   1   2   3  
Whipple Procedure 0   1   2   3  
Abdominal Perineal Resection 0   1   2   3  
 
Circulate - Gynecology:
Hysterectomy, abdominal 0   1   2   3  
Hysterectomy, vaginal 0   1   2   3  
Tubal ligation 0   1   2   3  
Tuboplasty 0   1   2   3  
Anterior posterior repair 0   1   2   3  
 
Circulate - Neurosurgery:
Craniotomy for Tumor 0   1   2   3  
Craniotomy for Aneurysm 0   1   2   3  
Ventricular Peritoneal Shunt 0   1   2   3  
Lumbar Laminectomy 0   1   2   3  
Cervical Laminectomy 0   1   2   3  
Posterior Sitting Laminectomy 0   1   2   3  
Transsphenoidal Hypophysectomy 0   1   2   3  
Ulnar Nerve Transposition 0   1   2   3  
 
Circulate - Opthalmology:
Cataract extraction with IOL 0   1   2   3  
Corneal transplant 0   1   2   3  
Scleral Buckling 0   1   2   3  
 
Circulate - Orthopedics:
Ankle Surgery 0   1   2   3  
Hand/Micro Hand Surgery 0   1   2   3  
Hip Prosthesis 0   1   2   3  
Knowles Pinning 0   1   2   3  
Spinal Fusion 0   1   2   3  
ACL Repair 0   1   2   3  
Shoulder Surgery 0   1   2   3  
Total Knee Surgery 0   1   2   3  
Total Hip Replacement 0   1   2   3  
ORIF 0   1   2   3  
 
Circulate - Plastics:
Liposuction 0   1   2   3  
Rhinoplasty 0   1   2   3  
Face Lift 0   1   2   3  
Skin Graft 0   1   2   3  
Breast Reconstruction 0   1   2   3  
Breast Reduction 0   1   2   3  
Cleft lip/palate repair 0   1   2   3  
Free/TRAM Flap 0   1   2   3  
 
Circulate - Thoracic & Open Heart:
Open Heart Bypass 0   1   2   3  
Open Heart Valve Replacement 0   1   2   3  
Aortic Aneurysm Repair 0   1   2   3  
Thoracotomy 0   1   2   3  
Lung Resection 0   1   2   3  
Pneumonectomy 0   1   2   3  
 
Circulate - Urology:
Cystectomy 0   1   2   3  
Kidney Transplant 0   1   2   3  
Percutaneous Nephrolithotomy 0   1   2   3  
Nephrectomy 0   1   2   3  
Prostatectomy 0   1   2   3  
TURP 0   1   2   3  
Ureterolithotomy 0   1   2   3  
Vasectomy 0   1   2   3  
 
Circulate - Vascular:
A-V access graft 0   1   2   3  
Carotid Endarterectomy 0   1   2   3  
Peripheral vascular bypass procedures 0   1   2   3  
Thrombectomy/embolectomy 0   1   2   3  
Vena cava filter/umbrella 0   1   2   3  
Vena cava ligation 0   1   2   3  
 
Circulate - Equipment:
Argon beam coagulator 0   1   2   3  
Bair Hugger 0   1   2   3  
Blood/fluid warmer 0   1   2   3  
Cell saver 0   1   2   3  
Use of Cavitron machine 0   1   2   3  
Lasers 0   1   2   3  
Pleur-evac disposable chest drainage 0   1   2   3  
Steri-vac aeration cabinet, 3-M, portable 0   1   2   3  
Steris unit 0   1   2   3  
Suction unit, disposable 0   1   2   3  
Washer sanitizer - AMSCO 0   1   2   3  
Washer sterilizer - AMSCO 0   1   2   3  
 
Circulate - Phlebotomy/IV Therapy:
Administration of blood/
blood products
0   1   2   3  
Drawing blood from central line 0   1   2   3  
Starting IVs with Angiocath 0   1   2   3  
 
Age-Specific Practice Criteria:
Please check the box corresponding to each age group for which you have expertise in providing age-appropriate nursing care. Pediatric (1 - 12years)  
Adolescents (12 - 18 years)  
Adult (19 - 65 years)  
Older Adult (Older than 65 years)  
 
Experience With Age Groups:
Calculate body weight to verify correct dosing of medication 0   1   2   3  
Assess immunization status for pediatric, and adolescent 0   1   2   3  
Set age-appropriate short-term and long-term goals in care planning 0   1   2   3  
Provide age-appropriate education, considering possible vision and hearing impairment for older than 65 years 0   1   2   3  
 
 
 
 


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