Operating Room

Information

Name *

Last 4 digits of SSN *

Phone *

Email *

Proficiency Scale

1 = No Experience

2 = Need Training

3 = Able to perform with supervision

4 = Able to perform independently

Work Setting

General OR *

CVOR *

Outpatient *

Trauma *

Peds-General OR *

Peds-CVOR *

First Assist *

Scrub Experience *

General Surgery

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

Aorta Repair *

Aorto-Bifemoral/Femoral-Pop Bypass Graft *

Cardiac Bypass Surgery *

Carotid Endarterectomy *

Endoscopic Vascular Procedures *

Femoral Popliteal Bypass Graft *

Laparoscopic Cardiac Surgery *

Robotic Assisted Cardiac Surgery *

Valve Replacement/Repair *

Ventricular Assist Device *

Scrub CV Surgery *

Thoracic

Endoscopic Thoracic Procedures *

Esophagoogastrectomy *

Mediastinotomy/Sternotomy *

Thoracoscopy/Nuss Procedure *

Thoracotomy *

Scrub Thoracic Surgery *

Orthopedic

Total Joint Replacement *

Closed Reduction of Fracture *

External Fixator *

Cannulated Hip Screws *

Bankhart Procedure *

Birmingham Procedure *

Arthroscopy *

Anterior Cruciate Ligament Reconstruction *

Open Reduction Internal Fixation *

Scrub Orthopedics *

Neurological

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 *

Genitourinary

Vasicaurethropexy *

Marshall Marchetti *

Circumcision *

Cystoscopy/Cystogram/Pyelogram *

Prostatectomy *

Nephrectomy *

Orchidectomy/Orchidopexy *

Ureterostomy *

Laparoscopic Assisted GU Procedures *

Robotic Assisted GU Procedures *

Scrub GU Surgery *

Gynecological

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

Endoscopic ENT Procedures *

Laryngectomy *

Mastoidectomy *

Myringotomy with Insertion of Tubes *

Radical Neck *

Septoplasty *

Tonsillectomy & Adenoidectomy *

Tracheostomy *

Tympanoplasty *

Scrub ENT Surgery *

Craniofacial/Oral

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

Blephoroplasty *

Breast Reconstruction with Implant *

Breast Reduction Mammoplasty *

Face Lift *

Mastectomy with Tram Flap Reconstruction *

Split Thickness Skin Graft *

Suction Lipectomy *

Scrub Plastics *

Transplants

Heart *

Lung *

Liver *

Pancreas *

Eye *

Organ Donation *

Scrub Transplants *

General Surgery

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

Circumcision *

Cystoscopy/Cystogram/Pyelogram *

Hydrocelectomy *

Nephrectomy *

Orchidectomy/Orchidopexy *

Repair of Hypospadias *

Retrograde Pyelogram *

Ureterostomy *

Scrub Peds GU *

Neuro

Craniotomy *

Insertion of Vagal Nerve Stimulator *

Insertion of VP Shunt *

Scrub Peds Neuro *

Cardiac/Vascular

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

Heart *

Kidney *

Liver/Pancreas *

Lung *

Organ Donation *

Scrub Peds Transplant *

Ophthalmology

Corneal Transplant *

Dacrocystorhinostomy *

Excision of Chalazion *

Eye Muscle Surgery *

Levator Resection *

Orbitotomy of Eye *

Repair of Ptosis *

Scrub Peds Opthalmology *

Ear/Nose/Throat

Cochlear Implant *

Laryngotracheoplasty *

Myringotomy with Tubes *

Septoplasty *

Suspension Microlaryngoscopy *

Tonsillectomy & Adenoidectomy *

Tracheostomy *

Turbinate Reduction *

Tympanoplasty/Tympanomastoidectomy *

Scrub Peds ENT *

Craniofacial/Oral/Plastics

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

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

Electrocautery (ESU) *

Laparoscopy Systems *

Neuro *

OR Fracture Tables (List Types) *

Orthopedic Total Joint Systems *

Power Equipment *

Robotics Systems (List Types) *

Spinal Fusion Instrumentation *

Professional Knowledge and Skills

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

Epic *

Cerner *

Eclipsys *

McKesson *

Meditech *

Other Computerized System *

Computerized Physician Order Entry *

Operating Room

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