1111 north 3rd street phoenix, arizona 85004 phone 602 · pdf file1111 north 3rd street...

1111 North 3rd StreetPhoenix, Arizona 85004

Phone 602-264-1444 Fax 602-264-1443

Copyright © 2014 Dependable Staffing Services, LLC. All rights reserved. of 7

OPERATING ROOM SKILLS CHECKLIST

Instructions: Please complete this checklist to enable us to match your skills and interests with available assignments.

Place an "X" in the appropriate column that best describes your experience level with each skill.

LEVELS OF PROFICIENCY:1. Experienced - performs well and independently (at least 1 year experience)2. Limited experience - some assistance or practice needed (6 months to 1 year experience)3. Little experience - need more experience, assistance required (less than 6 months experience)4. No experience

SKILLS 1 2 3 4

A. GENERAL SURGERY 1. Cholecystectomy/Cholangiogram ____ ____ ____ ____ 2. Hemorrhoidectomy ____ ____ ____ ____ 3. Imperforate Anus Reconstruction ____ ____ ____ ____ 4. Radical Mastectomy ____ ____ ____ ____ 5. Tracheostomy ____ ____ ____ ____ 6. Vagotomy ____ ____ ____ ____ 7. Saphenous Vein Ligation and Stripping ____ ____ ____ ____ 8. Lumbar Sympathectomy ____ ____ ____ ____ 9. Hepatic Resection ____ ____ ____ ____ 10. Circumcision ____ ____ ____ ____ 11. Abdominal Perineal Resection ____ ____ ____ ____ 12. Adrenalectomy ____ ____ ____ ____ 13. Colectomy ____ ____ ____ ____ 14. Herniorrhaphy, femoral, inguinal ____ ____ ____ ____ 15. Pancreatectomy/Pancreatogram ____ ____ ____ ____ 16. Splenectomy ____ ____ ____ ____ 17. Whipple Procedure ____ ____ ____ ____ 18. Bowel Resection ____ ____ ____ ____ 19. Pilonidal Cystectomy ____ ____ ____ ____ 20. Hiatal Herniorraphy, transabdominal ____ ____ ____ ____ 21. Colostomy/Ileostamy ____ ____ ____ ____ 22. Anal Fissurectomy ____ ____ ____ ____ 23. Appendectomy ____ ____ ____ ____ 24. Gastrectomy ____ ____ ____ ____ 25. Organ Procurement ____ ____ ____ ____ 26. Portal Caval Shunt ____ ____ ____ ____ 27. Thyroidectomy ____ ____ ____ ____

B. ORTHOPEDIC 1. Amputation: arm/leg ____ ____ ____ ____ 2. Insertion of McIntosh Tibial Plateau Prosthesis ____ ____ ____ ____ 3. Insertion of Swanson Finger Prosthesis ____ ____ ____ ____ 4. Tendon Transplants ____ ____ ____ ____ 5. Carpal Tunnel release ____ ____ ____ ____ 6. Putti Platt/Bankart Procedure ____ ____ ____ ____ 7. Spinal Fusion ____ ____ ____ ____


Phone 602-264-1444 Fax 602-264-1443


8. Patellectomy ____ ____ ____ ____ 9. Heel Cord Lengthening ____ ____ ____ ____ 10. Bunionectomy ____ ____ ____ ____ 11. Application of Halo Traction ____ ____ ____ ____ 12. Capsularrhaphy ____ ____ ____ ____ 13. Laminectomy ____ ____ ____ ____ 14. Repair Hammer Toes ____ ____ ____ ____ 15. Application of Spica Cast ____ ____ ____ ____ 16. Excision of Olecrannon Bursa ____ ____ ____ ____ 17. Cup Arthroplasty/Insertion Prosthesis ____ ____ ____ ____ 18. Sharranrd Procedure ____ ____ ____ ____ 19. Nailing Procedures A-O ____ ____ ____ ____ Lottes ____ ____ ____ ____ Jewett ____ ____ ____ ____ K Wires ____ ____ ____ ____ Schneider ____ ____ ____ ____ Kuntscher Rod ____ ____ ____ ____ Rush ____ ____ ____ ____

C. NEURO 1. Anterior Cervical Fusion ____ ____ ____ ____ 2. Laminectomy ____ ____ ____ ____ 3. Ulna Nerve Transplant ____ ____ ____ ____ 4. Craniectomy for Decompression Fracture ____ ____ ____ ____ 5. Burrholes for Subdural Hematoma ____ ____ ____ ____ 6. Meningocele Repair ____ ____ ____ ____ 7. Vinke Tong Insertion ____ ____ ____ ____ 8. Clipping of Intracranial Aneurysm ____ ____ ____ ____ 9. Carotid Ligation ____ ____ ____ ____ 10. Shunt Procedures; VP/VA/LP ____ ____ ____ ____ 11. Ventriculography Procedures ____ ____ ____ ____ 12. Cranioplasty ____ ____ ____ ____ 13. Crutchfield Tong Insertion ____ ____ ____ ____ 14. Cervical Sympathectomy ____ ____ ____ ____ 15. Hypophysectomy ____ ____ ____ ____ 16. Craniotomy ____ ____ ____ ____

D. GYN 1. Hyserectomy, vaginal ____ ____ ____ ____ 2. Hysterectomy, abdominal ____ ____ ____ ____ 3. Termination of Pregnancy ____ ____ ____ ____ 4. Caesarean Section ____ ____ ____ ____ 5. Laser Surgery ____ ____ ____ ____ 6. Marsupialization Bartholin Cyst ____ ____ ____ ____ 7. Colpotomy ____ ____ ____ ____ 8. Radium Insertion ____ ____ ____ ____ 9. Vaginal Reconstruction ____ ____ ____ ____ 10. Dilation and Curettage ____ ____ ____ ____ 11. Vaginectomy ____ ____ ____ ____ 12. Tubal Ligation ____ ____ ____ ____ 13. Marchetti-Marshall ____ ____ ____ ____ 14. Shirodkar Operation ____ ____ ____ ____

1111 North 3rd Street Phoenix, Arizona 85004

Phone 602-264-1444 Fax 602-264-1443


15. Salpingo-Oopherectomy ____ ____ ____ ____

E. UROLOGICAL 1. Vasectomy ____ ____ ____ ____ 2. Cystectomy ____ ____ ____ ____ 3. Hypospedius Repair ____ ____ ____ ____ 4. Nephrectomy ____ ____ ____ ____ 5. Circumcision ____ ____ ____ ____ 6. Prostatectomy, perineal ____ ____ ____ ____ 7. Protstectomy, suprapubic ____ ____ ____ ____ 8. Kidney Transplant ____ ____ ____ ____ 9. T.U.R. ____ ____ ____ ____ 10. Orchietomy ____ ____ ____ ____ 11. Ureterolithotomy ____ ____ ____ ____ 12. Pyeoplasty ____ ____ ____ ____

F. THORACIC/CARDIOVASCULAR 1. Closed Thoracotomy ____ ____ ____ ____ 2. Pericardiectomy ____ ____ ____ ____ 3. Tracheal Resection ____ ____ ____ ____ 4. Transthoracic Diaphragmatic Herniorrhaphy ____ ____ ____ ____ 5. Esophagectomy ____ ____ ____ ____ 6. Thoracoplasty ____ ____ ____ ____ 7. Mitral Commissurotomy ____ ____ ____ ____ 8. Closure Patent Ductus Arteriosis ____ ____ ____ ____ 9. Endocardial-Pacemaker Implantation ____ ____ ____ ____ 10. Myocaridal-Pacemaker Implantation ____ ____ ____ ____ 11. Correction Pectus Excavatum ____ ____ ____ ____ 12. Pneumonectomy/Lobectomy ____ ____ ____ ____ 13. First Rib Resection ____ ____ ____ ____ 14. Excision Cervical Rib ____ ____ ____ ____ 15. Revascularization Coronary Arteries ____ ____ ____ ____ 16. Heller Procedure ____ ____ ____ ____ 17. Resection Coarctation Aorta ____ ____ ____ ____ 18. Open Heart Procedure/CP Bypass Septal Defect Repairs ____ ____ ____ ____ Heart Valve Replacement ____ ____ ____ ____ 19. Aortic Femoral Bypass graft ____ ____ ____ ____ 20. Femoral Popliteal Bypass ____ ____ ____ ____ 21. Aortic Aneurysm w/graft replacement ____ ____ ____ ____ 22. Endoscopic Vein Harvesting ____ ____ ____ ____ 23. Cardiac Cath Lab-Intra-Aortic Balloon Pump ____ ____ ____ ____ 24. Septal Defects, ASV,VSD ____ ____ ____ ____ 25. Coronary Artery Bypass Graft ____ ____ ____ ____ 26. Off Pump Bypass ____ ____ ____ ____

G. VASCULAR 1. Shunts ____ ____ ____ ____ 2. Vena Cava Ligation ____ ____ ____ ____ 3. Embolectomy ____ ____ ____ ____ 4. Angiography ____ ____ ____ ____ 5. A -V access grafts ____ ____ ____ ____ 6. Peripheral Vascular Bypass Procedures ____ ____ ____ ____


Phone 602-264-1444 Fax 602-264-1443


7. Thrombectomy ____ ____ ____ ____ 8. Endarterectomy; carotid/femoral ____ ____ ____ ____ 9. Resection Carotid Aneurysm with Graft ____ ____ ____ ____

H. EAR, NOSE & THROAT 1. Luc-Caldwell ____ ____ ____ ____ 2. Maxillary Advancement with Hip Graft ____ ____ ____ ____ 3. Selective Osteotomy of Maxilla/Mandible ____ ____ ____ ____ 4. Cammendo Procedure ____ ____ ____ ____ 5. Open Reduction Facial Fractures ____ ____ ____ ____ 6. Submuccus Resection ____ ____ ____ ____ 7. Fenestration Procedure ____ ____ ____ ____ 8. Parotidectomy ____ ____ ____ ____ 9. Tympanoplasty ____ ____ ____ ____ 10. Laryngectomy ____ ____ ____ ____ 11. Radial Neck Dissection ____ ____ ____ ____ 12. Cleft Lip-Palate Repair ____ ____ ____ ____ 13. Myringotomy ____ ____ ____ ____ 14. Sinusotomy ____ ____ ____ ____ 15. Ethymoidectomy ____ ____ ____ ____ 16. Open Reduction Nasal Fracture ____ ____ ____ ____ 17. Tonsillectomy ____ ____ ____ ____ 18. Frontal Flap Sinus Procedure ____ ____ ____ ____ 19. PE Tube Insertion ____ ____ ____ ____ 20. Myringoplasty ____ ____ ____ ____ 21. Mastoidectomy ____ ____ ____ ____ 22. Ranulectomy ____ ____ ____ ____ 23. Closed Reduction Nasal Fracture ____ ____ ____ ____ 24. Nasal Ploypectomy ____ ____ ____ ____ 25. Stapedectomy ____ ____ ____ ____ 26. Excision Salivary Gland Tumor ____ ____ ____ ____ 27. Open Reduction Tripod Fracture ____ ____ ____ ____ 28. Tracheostomy ____ ____ ____ ____ 29. Glossectomy ____ ____ ____ ____ 30. Pharyngeal Flap Procedure ____ ____ ____ ____

I. EYE 1. Pterygium Repair ____ ____ ____ ____ 2. Corneal Transplant ____ ____ ____ ____ 3. Ocutome ____ ____ ____ ____ 4. Dacryocystorlfinostomy ____ ____ ____ ____ 5. Microscope ____ ____ ____ ____ 6. Enucleation ____ ____ ____ ____ 7. Repair of Retinal Detachment ____ ____ ____ ____ 8. Orbital Implant ____ ____ ____ ____ 9. Phacoemulsifier ____ ____ ____ ____ 10. Repair Orbital Blowout Fracture ____ ____ ____ ____ 11. Dacryocystectomy ____ ____ ____ ____ 12. Cataract Extraction ____ ____ ____ ____ 13. Recession Resection ____ ____ ____ ____ 14. Diathermy Operation ____ ____ ____ ____ 15. Iridectomy ____ ____ ____ ____


Phone 602-264-1444 Fax 602-264-1443


J. ORAL 1. Closed reduction facial fractures/wiring ____ ____ ____ ____ 2. Extraction of Impacted Molars ____ ____ ____ ____ 3. Extraction of Deciduous Teeth ____ ____ ____ ____ 4. Excision Odontoma ____ ____ ____ ____

K. CARDIOVASCULAR RESUSCITATION 1. Rhinoplasty ____ ____ ____ ____ 2. Mentoplasty ____ ____ ____ ____ 3. Blepheroplasty ____ ____ ____ ____ 4. Reduction Mammoplasty ____ ____ ____ ____ 5. Reconstructive ____ ____ ____ ____ 6. Augmentation Mammoplasty ____ ____ ____ ____ 7. Otoplasty ____ ____ ____ ____ 8. Cleft-Lip Palate Repair ____ ____ ____ ____ 9. Split Thickness Skin Grafting ____ ____ ____ ____ 10. Dermabrasion ____ ____ ____ ____ 11. Scar Revisions ____ ____ ____ ____ 12. Skin Grafting ____ ____ ____ ____ 13.Liposuction ____ ____ ____ ____

L. ENDOSCOPIC 1. Gastroscopy ____ ____ ____ ____ 2. Sigmoidoscopy ____ ____ ____ ____ 3. Bronchoscopy ____ ____ ____ ____ 4. Laryngoscopy ____ ____ ____ ____ 5. Culdoscopy ____ ____ ____ ____ 6. Mediastinoscopy ____ ____ ____ ____ 7. Laparoscopy ____ ____ ____ ____ 8. Esophagoscopy ____ ____ ____ ____ 9. Cystoscopy ____ ____ ____ ____

M. CARDIOVASCULAR RESUSCITATION 1. Intubation ____ ____ ____ ____ 2. Mouth to Mouth Resuscitation ____ ____ ____ ____ 3. Ambu ____ ____ ____ ____ 4. Cardiac Compression ____ ____ ____ ____

N. TRAUMA 1. Motor Vehicle Accidents ____ ____ ____ ____ 2. Amputations ____ ____ ____ ____ 3. Gunshot/Stab wounds ____ ____ ____ ____ 4. Burns ____ ____ ____ ____

O. INTRAVENOUS THERAPY 1. Medicut ____ ____ ____ ____ 2. Jelco ____ ____ ____ ____ 3. Intracath ____ ____ ____ ____ 4. Regular Intravenous Set ____ ____ ____ ____ 5. Scalp Vein ____ ____ ____ ____


Phone 602-264-1444 Fax 602-264-1443


P. MISCELLANEOUS EQUIPMENT 1. Disposable Bovie Plates ____ ____ ____ ____ 2. K-Pad Unit ____ ____ ____ ____ 3. Pneumatic Tube System ____ ____ ____ ____ 4. Washer Sterilizer--AMSCO ____ ____ ____ ____ 5. Ultrasonic Cleanser--AMSCO ____ ____ ____ ____ 6. Washer Sanitizer--AMSCO ____ ____ ____ ____ 7. Flash Autoclave--AMSCO ____ ____ ____ ____ 8. Ethylene Oxide Sterilizer--AMSCO ____ ____ ____ ____ 9. Defibrillator-Datascope 680 Resuscitation ____ ____ ____ ____ 10. Aquamatic K Thermia Unit ____ ____ ____ ____ 11. Kiddie Pneumatic Tourniquet ____ ____ ____ ____ 12. Portable Light ____ ____ ____ ____ 13. Vaccum Curettage ____ ____ ____ ____ 14. Hemokinetitherm-Blood Warmer ____ ____ ____ ____ 15. Eye Magnet ____ ____ ____ ____ 16. Nitrous Oxide Bank ____ ____ ____ ____ 17. Auto Suture, TA 30, Stapling Instrument ____ ____ ____ ____ 18. Auto Suture, TA 55, Stapling Instrument ____ ____ ____ ____ 19. Auto Suture, TA 90, Stapling Instrument ____ ____ ____ ____ 20. Auto Suture, GIA, Stapling Instrument ____ ____ ____ ____ 21. Pleur-e-vac Units (Disp. Chest Drainage) ____ ____ ____ ____ 22. Vac-pac Positioner ____ ____ ____ ____ 23. Blood Bank Refrigerator ____ ____ ____ ____ 24. Emerson-Thoracic Pump ____ ____ ____ ____ 25. Nerve Stimulator ____ ____ ____ ____ 26. Portable Cardiac Monitor, Datascope 850 ____ ____ ____ ____ 27. Cry-Opthalmic Unit ____ ____ ____ ____ 28. AOMI, Fiber Optic Luminator ____ ____ ____ ____ 29. PILLING, Fiber Optic Luminator ____ ____ ____ ____ 30. Orthopedic Arm Board with Drain ____ ____ ____ ____ 31. Bovie Electrosurgical Unit ____ ____ ____ ____ 32. Dual Tract Lights (bulb changing; handles) ____ ____ ____ ____ 33. Kreiselman Resuscitator ____ ____ ____ ____ 34. Steri-vac-neration Cabinet, 3-M, portable ____ ____ ____ ____ 35. Electrodyne-Cardiac Montior & Pacemaker ____ ____ ____ ____ 36. Conductometer ____ ____ ____ ____ 37. Operating Microscope ____ ____ ____ ____ 38. Cell Saver ____ ____ ____ ____ 39. Laser ____ ____ ____ ____ 40. Defibrillator-Electrodyne ____ ____ ____ ____ 41. Hall Neurotome ____ ____ ____ ____ 42. Nesq Graft ____ ____ ____ ____ 43. Operating Room Table, Castle 5 Section ____ ____ ____ ____ 44. Ohio Suction Units ____ ____ ____ ____ 45. Suction Unit, Disposable ____ ____ ____ ____ 46. Tele-thermometer ____ ____ ____ ____ 47. Compression Set, Zimmer ____ ____ ____ ____ 48. Drills Smith Cranial ____ ____ ____ ____ Hall Air Driver ____ ____ ____ ____ Hall Dental ____ ____ ____ ____ Chayes ____ ____ ____ ____


Phone 602-264-1444 Fax 602-264-1443


Jordan Day ____ ____ ____ ____ A-O ____ ____ ____ ____ 49. Dermatome Cordless Davol Unit ____ ____ ____ ____ Brown ____ ____ ____ ____ Padgett ____ ____ ____ ____ Castroviejo Electro-Kerotome ____ ____ ____ ____

Age Specific Experience Circle each of the following age groups you have experience providing age specific care to:

Neonatal Infant-Children(0-11) Adolescent (12-18) Adult Geriatric

_______________________________________________ ________________ Employee Signature Date

1111 north 3rd street phoenix, arizona 85004 phone 602 · pdf file1111 north 3rd street...

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