GENERAL INFORMATION

Note: * Denotes a required field.

Please enter your full name as it appears on your Social Security Card: First Name   Middle Name   Last Name  * Please enter the Last Four digits of your Social Security Number:  -   -   *       Please check here if you do not hold a valid social security card. Please provide your contact information: Phone Number  * E-mail Address  * Confirm E-mail Address  * Type your e-mail address again above.

This profile is for use by healthcare professionals in the Operating Room Nursing discipline and specialty. It will not be a determining factor for the program.

CHECKLIST INSTRUCTIONS

Please mark your level of experience      1. No theory and/or experience      2. Limited experience/need supervision and/or support      3. Experienced/minimal support needed to perform      4. Proficient/can perform independently

ADULTS

WORKSETTING

1

2

3

4

General OR

CVOR

Outpatient

Trauma

Peds-General OR

Peds-CVOR

First Assist

Scrub Experience

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

CARDIOVASCULAR

1

2

3

4

Aorta Repair

Aorto-Bifemoral/Femoral-Pop Bypass Graft

Cardiac Bypass Surgery

Carotid Endarterectomy

Endoscopic Vascular Procedures

Femoral Popliteal Bypass Graft

Laparascopic Cardiac Surgery

Robotic Assisted Cardiac Surgery

Valve Replacement/Repair

Ventricular Assist Device

Scrub CV Surgery

THORACIC

1

2

3

4

Endoscopic Thoracic Procedures

Esophagoogastrectomy

Mediastinotomy/Sternotomy

Thoracoscopy/Nuss Procedure

Thoracotomy

Scrub Thoracic Surgery

ORTHOPEDIC

1

2

3

4

Total Joint Replacement

Closed Reduction of Fracture

External Fixator

Cannulated Hip Screws

Bankhart Procedure

Birmingham Procedure

Carpal Tunnel Release

Arthroscopy

Anterior Cruciate Ligament Reconstruction

Open Reduction Internal Fixation

Scrub Orthopedics

NEUROLOGICAL

1

2

3

4

Craniotomy

Steriotactic 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

GENITOURINARY

1

2

3

4

Vasicaurethropexy

Marshall Marchetti

Circumcision

Cystoscopy/Cystogram/Pyelogram

Prostatectomy

Nephrectomy

Orchidectomy/Orchidopexy

Ureterostomy

Laparoscopic Assisted GU Procedures

Robotic Assisted GU Procedures

Scrub GU 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

EAR/NOSE/THROAT

1

2

3

4

Endoscopic ENT Procedures

Laryngectomy

Mastoidectomy

Myringotomy with Insertion of Tubes

Radical Neck

Septoplasty

Tonsillectomy & Adenoidectomy

Tracheostomy

Tympanoplasty

Scrub ENT 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

PLASTIC

1

2

3

4

Blephoroplasty

Breast Reconstruction with Implant

Breast Reduction Mammoplasty

Face Lift

Mastectomy with Tram Flap Reconstruction

Split Thickness Skin Graft

Suction Lipectomy

Scrub Plastics

TRANSPLANTS

1

2

3

4

Heart

Lung

Liver

Pancreas

Eye

Organ Donation

Scrub Transplants

OPHTHALMOLOGY

1

2

3

4

Cataract Extraction with Implant

Vitrectomy

Scleral Buckle

Cataract Aspiration; Anterior Vitrectomy

Corneal Transplant

Scrub Ophthalmology

PEDIATRICS

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

Laparascopic General Surgery Procedures

Liver Biopsy

Percutaneous Endoscopic Gastrostomy

Thoracoscopy/Nuss Procedure

Scrub Peds General Surgery

GENITOURINARY

1

2

3

4

Circumcision

Cystoscopy/Cystogram/Pyelogram

Hydrocelectomy

Nephrectomy

Orchidectomy/Orchidopexy

Repair of Hypospadias

Retrograde Pyelogram

Ureterostomy

Scrub Peds GU

NEURO

1

2

3

4

Craniotomy

Insertion of Vagal Nerve Stimulator

Insertion of VP Shunt

Laminectomy

Scrub Peds Neuro

CARDIAC/VASCULAR

1

2

3

4

Arterial Switch

ASD/VSD Repair

Atrial Septectomy

Bidirectional Glenn

BT Shunt

ECMO Insertion/Decannulation (Cardiac)

Fontan Procedure

Norwood Procedure

Pacemaker

PDA Ligation

Repair of Coarctation of Aorta

Ross Procedure

Tetralogy of Fallot Repair

Valve Repair/Replacement

Ventricular Assist Device

Scrub Peds Cardiac/Vascular

TRANSPLANT

1

2

3

4

Heart

Kidney

Liver/Pancreas

Lung

Organ Donation

Scrub Peds Transplant

OPHTHALMOLOGY

1

2

3

4

Corneal Transplant

Dacrocystorhinostomy

Excision of Chalazion

Eye Muscle Surgery

Levator Resection

Orbitotomy of Eye

Repair of Ptosis

Scrub Peds Opthalmology

EAR/NOSE/THROAT

1

2

3

4

Cochlear Implant

Laryngotracheoplasty

Myringotomy with Tubes

Septoplasty

Suspension Microlaryngoscopy

Tonsillectomy & Adenoidectomy

Tracheostomy

Turbinate Reduction

Tympanoplasty/Typanomastoidectomy

Scrub Peds ENT

CRANIOFACIAL/ORAL/PLASTICS

1

2

3

4

Craniectomy

Craniofacial Reconstruction

Dental Surgery

Leforte 1 Maxillary/Sagittal Osteotomy

Mandibular Osteotomy

ORIF Mandibular Fracture

Otoplasty

Reconstruction of Ear

Repair of Cleft Lip, Nose, Palate

Rhinoplasty

Skin Graft

Scrub Peds C-Fl/Oral/Plastics

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

OR EQUIPMENT

1

2

3

4

Electrocautery (ESU)

Laparoscopy Systems

Neuro

OR Fracture Tables

Orthopedic Total Joint Systems

Power Equipment

Robotics Systems

Spinal Fusion Instrumentation

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

1

2

3

4

Epic

Cerner

Eclipsys

McKesson

Meditech

Other Computerized System

Computerized Physician Order Entry

EMR Conversion

Yes

No

CERTIFICATIONS

1

2

3

4

BLS

PALS

Certified Nurse Operating Room

Registered Nurse First Assist

Please read and agree to the statements below by marking the checkbox. You will not be able to submit until you have marked the checkbox. * I attest that the information I have given is true and accurate to the best of my knowledge and that I am the individual completing this form. I hereby authorize Hudson Staffing to release this Operating Room Nursing Skills Checklist to the client facilities in relation to consideration of employment as a healthcare professional with those facilities.

Privacy Note: Hudson Staffing will record anonymous electronic information about your connection when you click on the submit button. This information is used for security purposes only. This information will include your IP Address (54.90.204.233) which will be used as a digital signature.