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This checklist was electronically signed on (Today’s date)
This checklist is designed to guide our client facilities in assessing your proficiency in your nursing specialty. Please use the scale provided to indicate your level of experience and expertise in each of the areas listed below.
Skill Level Indicator:
★ = No Experience
★★ = Requires Training
★★★ = Capable with Supervision
★★★★ = Capable Independently
Advanced directives
Patient / family teaching
Restrictive devices (restraints)
Lift / transfer devices
Specialty beds
End of life care / palliative care
Wound assessment & care
Automated Medication Dispensing System, Pyxis, Omnicell, or other
Bar coding for medication administration
Diabetic care and education
Blood Glucose Monitor (BGM)
Cardioversion / defibrillation
Electronic ICU
National Patient Safety Goals
Accurate patient identification
Effective communication
Interpretation & communication of lab values
Medication administration
Medication reconciliation
Labeling (medications & specimens)
Anticoagulation therapy
Monitoring conscious sedation
Pain assessment & management
Infection control
Universal precautions
Isolation
Minimize risk for falls
Prevention of pressure ulcers
Use of rapid response teams
Awareness of HCAHPS
Cardiac arrest/adult CPR infant-child CPR
Patient/family teaching
Lift/transfer devices
Restrictive devices
End of life care/palliative care
Diabetic management in the OR
Accurate patient identifcation/surgical site verfcation with OR team
Interpretation & timely communication of lab values
Anticoagulant therapy
MDRO HAI
Hand hygiene WHO/CDC
CLABSI infections
CAUTI prevention
Identify patient suicide risk
Universal protocol
Surg site infection control
Bowel resection
Cholecystectomy/cholangiogram
Colostomy/ileostomy 0 1 2 3 4 5
Gastrectomy
Hemicolectomy
Hepatic resection
Herniorrhaphy-femoral/inguinal
Hiatal herniorrhaphy
Pancreatectomy
Organ procurement
Radical mastectomy
Saphenous vein ligation/stripping
Splenectomy
Thyroidectomy
Tracheostomy
Vagotomy
Familiarity with pediatric procedures
Abdominal perineal resection
Adrenalectomy bariatric surgery (gastric bypass)
Bronchoscopy
Colonoscopy
Culdoscopy
Cystoscopy
Esophagoscopy
Gastroscopy
Hysteroscopy
Caesarean section
Dilation & curettage
Hysterectomy - vaginal
Hysterectomy - abdominal
Radium insertion
Salpingo-oopherectomy
Shirodkar procedure
Termination of pregnancy
Tubal ligation
Vaginectomy
Appendectomy
Cholecystectomy
Colon resection
Gastric bypass
Hernia repair
Nephrectomy
Prostatectomy
Sinus surgery
Salpingo-oophorectomy
Vaginal hysterectomy
Laryngoscopy
Mediastinoscopy
Pelviscopy
Sigmoidoscopy
Thoracoscopy
Whipple
Nissen fundoplication
Achilles tendon repair
Amputation
Arthroscopy/anthrotomy
Closed pinning & reduction of extremities
External compression devices
Hip compression nails & lag screws
Total joint replacement - knee
Total joint replacement - hip
Total joint replacement - shoulder
Spica cast
ORIF - shoulder, hip, humerus
Repair of dislocation
Patellectomy
Tendon implants & reanastomosis
Circumcision
Cystoscopy/ureteroscopy
Cystectomy
Hypospadias repair
Implants
Lithotripsy
Orchiectomy
Ureterolithotomy
TURP
PVP - Photo Vaporization of Prostate
Vasectomy
Kyphoplasty
A-V malformation
Laparoscopic spine procedures
Burr holes for subdural hematoma
Carotid ligation
Cervical sympathectomy
Cranioplasty
Craniotomy
Disectomy/laminectomy
Halo traction application
Insertion of nerve stimulator
Myelomeningocele repair
Shunt procedure
Spinal fusions
Ventriculostomy
Abdominal lipectomy
Blepharoplasty
Face lift
Mammoplasty
Augmentation
Reduction
Liposuction
Otoplasty
Scar revisions
Skin grafting
Cataract extraction
IOL implants
Corneal transplant
Orbital implant
Enucleation
Repair of retinal detachment
Scleral buckle
Caldwell-luc
Cleft lip/palate repair
Laryngectomy
Radical neck
Tonsillectomy & adenoidectomy
Mandibulectomy
Mastoidectomy
Rhinoplasty/septoplasty
Sinusotomy
Angiography
A-V access graft
Aortic aneurysm: abdominal
Peripheral vascular bypass procedures
Endarterectomy: carotid
Thrombectomy
Embolectomy
Vena cava ligation
Endoluminal AAA
Carotid revascularization endarterectomy
Cerebral aneurysm repair
Bone
Corneal
Harvesting
Heart/lung
Kidney
Liver
Multi organ
Pancreas
Skin
Aortic femoral bypass graft
Femoral popliteal bypass
Pacemaker implantation/explanation
Care of patients with pacemaker
Care of patients with intra-aortic balloon pump
Septal defects, ASV, VSD
Coronary Artery Bypass & Graft (CABG) on pump
Valve replacement/repair
Aortic aneurysm
Thoracotomy/lobectomy
Endoscopic vein harvesting
Maze procedure
Burns
Gunshot/stab wounds
Motor vehicle accidents
Traumatic amputations
Argon beam coagulator
Camera/video systems
Cell saver
Cidex soak
Cryo-ophthalmic unit
Cavitron Ultrasonic Surgical Aspirator (CUSA)
Hypo/hyperthermia unit
Drill and saws
Electrosurgical unit
Fiber optic luminator
Cavitron
Autoclave
Fracture tables
Harmonic scalpel
Ligasure
Stapling devices
Mesh graft/dermatone
Microscopes
Nitrogen tank
Pneumatic tourniquet
Stealth
Steris unit
Pulsevac irrigation
Autotransfusion system
Laser equipment
Care of scopes & fberoptic equipment
Venodyne robotics (Da Vinci)
Position patient
Surgical draping
Creates sterile field
Maintains sterile field
Provides wound exposure
Use of instruments
Use of retractors
Suctioning and sponging techniques
Use of medical devices
Use of medications/solutions
Clamping blood vessels
Coagulating bleeding points
Ligating vessels
Other procedures in collaboration with surgeon
Safe tissue handling
Safe cutting of tissue
Suturing muscle
Suturing fascia
Suturing subcutaneous tissue
Suturing skin tissue
Assist with dressings/drains
Placing drains
Assist with cannulation
Assist with decannulation
Knot tying
Assists: SC local anesthesia
Preop nursing assessment
Periop nursing assessment
Write preop orders per hospital protocol
Environmental sanitation
Monitors surgical environment
Controls surgical environment
Working knowledge of equipment
Laser safety
Working knowledge of supplies
Sponge, needle, instrument count
Write post-op protocol orders per hospital protocol
Write opperative notes per hospital protocol
Participate in postop rounds & D/C planning
Electrosurgery experience
Recognize & intervene for safety hazards
Newborn/neonate (birth-30 days)
Infant (31 days- 1 year)
Toddler (ages 2-3 yrs)
Preschool (ages 4-5 yrs)
School Age (ages 6-12 yrs)
Adolescent (ages 13-21 yrs)
Young Adult (ages 22-39)
Adult (ages 40-64)
Older Adult (ages 65+)
I hereby certify that ALL information I have provided 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.
