Proficiency Scale:

1 = No experience

2 = Need Training

3 = Able to perform with supervision

4 = Able to perform independently

GENERAL SURGERY

1

2

3

4

Abdominal Perineal Resection

Appendectomy/Cholescystectomy

Breast Biopsy

Colon Resection/Surgery

Gastrectomy

Gastric Bypass/Roux-en-Y

Hemorrhoidectomy

Herniorrhaphy - Inguinal, Ventral, Femoral, Umbilical

Laparoscopic General Surgeries

Laparoscopic Nissen Fundoplication

Mastectomy

Splenectomy

Thyroidectomy

Scrub General Surgery

THORACIC

1

2

3

4

Endoscopic Thoracic Procedures

Esophagoogastrectomy

Mediastinotomy/Sternotomy

Thoracoscopy/Nuss Procedure

Thoracotomy

Scrub Thoracic Surgery

NEUROLOGICAL

1

2

3

4

Craniotomy

Stereotactic Guided Brain Biopsy

Laminectomy

Laparoscopic Anterior Laminectomy

Insertion of Vagal Nerve Stimulator

Insertion of VP Shunt

Spinal Fusion

Anterior Cervical Discectomy with Fusion

Posterior Cervical Laminectomy

Scrub Neurological Surgery

GYNECOLOGICAL

1

2

3

4

Abdominal Hysterectomy

Anterior Posterior Repair

C-Section

D & C

Laparoscopic Assisted Hysterectomy

Laparotomy with Microtuboplasty

Robotic Assisted GYN Procedures

Vaginal Delivery

Vaginal Hysterectomy

Scrub Gyn Surgery

CRANIOFACIAL/ORAL

1

2

3

4

Craniectomy

Craniofacial Reconstruction

Dental Surgery

Leforte 1 Maxillary/Sagittal Osteotomy

ORIF Mandibular Fracture

Otoplasty

Reconstruction of Ear

Removal of Arch Bars

Repair of Cleft Lip, Nose, Palate

Rhinoplasty

Scrub Craniofacial/Oral

TRANSPLANTS

1

2

3

4

Heart

Lung

Liver

Pancreas

Eye

Organ Donation

Scrub Transplants

GENERAL SURGERY

1

2

3

4

Anal Fistulectomy/Anoplasty

Appendectomy/Cholecystectomy

Biopsy (Mass, Muscle, Lymph Node)

Bronchoscopy

Colostomy

Esophagogastroduodenoscopy w/ Biopsy

Esophagoscopy

Exploratory Laparotomy

Flexible Sigmoidoscopy

Fundoplication

Gastrostomy

Herniorrhaphy

Insertion of Port-a-Cath, Hickman, Broviac

Laparoscopic General Surgery Procedures

Liver Biopsy

Percutaneous Endoscopic Gastrostomy

Thoracoscopy/Nuss Procedure

Scrub Peds General Surgery

NEURO

1

2

3

4

Craniotomy

Insertion of Vagal Nerve Stimulator

Insertion of VP Shunt

Laminectomy

Scrub Peds Neuro Surgery

TRANSPLANT

1

2

3

4

Heart

Kidney

Liver/Pancreas

Lung

Organ Donation

Scrub Peds Transplant

EAR/NOSE/THROAT

1

2

3

4

Cochlear Implant

Laryngotracheoplasty

Myringotomy with Tubes

Septoplasty

Suspension Microlaryngoscopy

Tonsillectomy & Adenoidectomy

Tracheostomy

Turbinate Reduction

Tympanoplasty/Tympanomastoidectomy

Scrub Peds ENT

ORTHOPEDICS

1

2

3

4

Acetabuloplasty/Triple Innominate

Arthroscopy of Knee, Wrist, Shoulder

Closed Reduction, Percutaneous Pin

External Fixator (Ilizarov/Orthofix)

ORIF Shoulder, Humerus, Tibia, Femur

Osteotomy/VDRD/Calcaneal/Metatarsal

Spinal Fusion/Spinal with Instrumentation

Tendoachilles Lengthening

Scrub Peds Ortho

PROFESSIONAL KNOWLEDGE AND SKILLS

1

2

3

4

Malignant Hyperthermia Protocol

Administer and Monitor Moderate Sedation

Universal Protocol for Wrong Site Surgery

National Patient Safety Goals/Core Measures

Fall Risk Assessment/Prevention

Pressure Ulcer Risk Assessment/Prevention

Restraints/Use of Least Restrictive Device

Age Specific/Population-Based Care

Isolation Precautions

Infection Prevention

EMR Conversion	Expiry Date:
BLS
NRP
PALS
Certified Nurse Operating Room
Registered Nurse First Assist
Other: Specify

I hereby certify that ALL information I have provided to Tricehealthcare on this skills checklist and all other documentation, is true and accurate. I understand and acknowledge that any misrepresentation or omission may result in disqualification from employment and/or immediate termination.

I have filled out this skills checklist to the best of my knowledge and agree that all the information provided is correct.

Personal Information

Proficiency Scale:

WORKSETTING

GENERAL SURGERY

CARDIOVASCULAR

THORACIC

ORTHOPEDIC

NEUROLOGICAL

GENITOURINARY

GYNECOLOGICAL

EAR/NOSE/THROAT

CRANIOFACIAL/ORAL

PLASTIC

TRANSPLANTS

OPHTHALMOLOGY

GENERAL SURGERY

GENITOURINARY

NEURO

CARDIAC/VASCULAR

TRANSPLANT

OPHTHALMOLOGY

EAR/NOSE/THROAT

CRANIOFACIAL/ORAL/PLASTICS

ORTHOPEDICS

OR EQUIPMENT

PROFESSIONAL KNOWLEDGE AND SKILLS

EMR