Peri-Operative

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

IV Therapy

Start peripheral IV - angio cath *

IV Therapy - Assist with

Insertion of A-lines *

Insertion of CVP - jugular *

Insertion of CVP - subclavian *

Insertion of Swan-Ganz *

Drawing blood from central line *

Drawing venous blood *

Administration of blood and products

Packed red blood cells *

Plasma/Albumin *

Whole blood *

General Surgery

Abdominal perineal resection *

Adrenalectomy *

Anal fissurectomy *

Appendectomy *

Bowel resection *

Breast biopsy *

Colectomy *

Colostomy/Ileostomy *

Esophageal resection *

Exploratory laparotomy *

Gastrectomy *

Gastroplasty *

Hemorrhoidectomy *

Hemicolectomy *

Hepatic resection *

Herniorrhaphy - femoral *

Herniorrhaphy - inguinal *

Herniorrhaphy - umbilical *

Herniorrhaphy - hiatal transabdominal/transthoracic *

Hiatal hernia repair *

Insertion - Hickman *

Insertion - Groshong *

Insertion - Portacath *

Hydrocelectomy *

Imperforate anus reconstruction *

Lumbar sympathectomy *

Omphalocele repair *

Pancreatectomy / pancreatogram *

Pilonidal cystectomy *

Portal caval shunt *

Pyloric stenosis *

Radical mastectomy *

Saphenous vein ligation and stripping *

Sentinel node biopsy *

Splenectomy *

Tenchknoff duct cyst excision *

Thyroglossal duct cyst excision *

Thyroidectomy *

Vagotomy *

Thoracic and Open Heart

Cervical rib excision *

Chamberlain procedure *

Closed thoracotomy *

Correction pectus excavatum *

Esophagectomy *

Heller procedure *

Mitral commissurotomy *

Mitral or aortic valve replacement *

IAPB insertion *

CABG *

Cardiac valve replacement *

Patent ductus arteriosus repair *

Septal defect repairs *

Pacemaker implantation - endocardial *

Pacemaker implantation - myocardial *

Pacemaker - temporary *

Pericardiectomy *

Pericardial window *

Resection coarctation aorta *

Portocaval shunt *

Tetralogy of fallot *

Thoracoplasty *

Tracheal resection *

Transthoracic diaphragmatic herniorrhaphy *

Vascular

A-V access graft *

Aortic aneurysm with graft replacement *

Endarterectomy/carotid - femoral *

Fem-pop bypass *

Peripheral vascular bypass procedures *

Resection carotid aneurysm with graft *

Thrombectomy/embolectomy *

Vena cava filter/umbrella *

Vena cava ligation *

Neurology

A-V malformation *

Anterior cervical fusion *

Anterior laparoscopic spine procedures *

Anterior lumbar interbody fusion (ALIF) *

Burr holes for subdural hematoma *

Carotid ligation *

Cervical sympathectomy *

Craniectomy for decompression fracture *

Discectomy *

Hypophysectomy *

Insertion nerve stimulators *

Insertion medication pumps *

Laminectomy *

Myelomeningocele repair *

Pedicle screw insertion *

Posterior lumbar interbody fusion (PLIF) *

Shunt procedure/VP, VA/LP *

Spine fusion *

Ulnar nerve transfer *

Ventriculography / ventriculoscopy *

Ventriculostomy *

Neurology - Cranioplasty/craniotomy

Clipping of aneurysm *

Tumor excision *

Stealth craniotomy *

Urology

Adult circumcision *

Cystectomy *

Cystoscopy/ureteroscopy *

Hypospadias repair *

Ileal loop *

Implants - penile and testicular *

Lithotripsy *

Nephrectomy *

Nephrolithotomy *

Orchiopexy *

Prostatectomy - perineal *

Prostatectomy - supra-pubic *

Pyleoplasty *

Radical node dissection *

Scott incontinence device *

TURP *

Ureterolithotomy *

Vasectomy *

Vasovasostomy *

Waterhouse procedure *

Gynecology

Cesarean section *

Colpotomy *

Dilation and curettage (D&C) *

Hysterectomy - abdominal *

Hysterectomy - vaginal *

Marshall - Marchetti *

Marsupialization, Bartholin cyst *

Ovarian cystectomy *

Radium insertion *

Salpingo-oophorectomy *

Sacral spinous fixation *

Shirodkar procedure *

Suction curettage *

Termination of pregnancy *

Tubal ligation *

Vaginal reconstruction *

Vaginectomy/vulvectomy *

Orthopedics

Acetabular/pelvic ORIF *

Achilles tendon repair *

Amputation - leg, arm *

Anterior cruciate ligament repair *

Application of external fixators - extremities *

Application of external fixators - pelvis *

Application of halo traction *

Arthrotomy *

Bipolar/unipolar hips *

Bunionectomy *

Calcaneal reconstruction *

Capsulorrhaphy *

Carpal tunnel release *

Closed reduction fracture *

Hand surgery with implants *

Harrington rod instrumentation and/or Dwyer procedure *

Heel cord lengthening *

Laminectomy *

Olecranon bursa, excision of *

ORIF, internal fixation with compression set *

Patellectomy *

Putti-Platt/Bankart procedure/rotator cuff repair *

Reduction with compression sets *

Reimplantation of digits *

Repair hammer toes *

Sacro-iliac (SI) joint screws *

Sharrard procedure *

Spica cast, application *

Spinal fusion *

Tendon transplants (hand and foot) *

Orthopedics - Arthroscopy

Ankle *

Elbow *

Knee *

Shoulder *

Orthopedics - Hip Compression Nails and Lag Screws

Jewett *

Kuntscher rod *

Lottes *

Rush *

Schneider *

Zimmer *

Iliac crest bone graft *

Insertion Austin Moore hip prosthesis *

Orthopedics - Intramedullary Rods

Extraction *

Femoral *

Humeral *

Insertion *

Supracondylar *

Tibial *

Orthopedics - Total Joint Replacements/Revisions

Hip *

Knee *

Shoulder *

Plastics

Abdominal lipectomy *

Abdominalplasty *

Blepharoplasty *

Cleft lip repair *

Dermabrasion *

Face lift *

Mentoplasty *

Otoplasty *

Pedicle grafts *

Rhytidectomy *

Scar revisions *

Split thickness skin grafting *

Tissue expanders *

Plastics - Mammoplasty

Augmentation *

Reduction *

Tramflaps with reconstructive mammoplasty *

Ear, Nose and Throat

Adenoidectomy *

Caldwell - Luc *

Cleft lip/palate repair *

Closed reduction nasal fx *

Ethmoidectomy *

Excision of salivary gland tumor *

Fenestration procedure *

Frontal flap sinus procedure *

Glossectomy *

Laryngectomy *

Mandibulectomy *

Mastoidectomy *

Maxillary advancement with graft *

Maxillectomy *

Myringoplasty *

Myringotomy with PE tube insertion *

Nasal polypectomy *

Open reduction facial fx *

Open reduction nasal fx *

Parotidectomy *

Pharyngeal flap procedure *

Radical neck dissection *

Ranulectomy *

Rhinoplasty/septoplasty *

Selective osteotomy of maxilla/mandible *

Sinus endoscopy *

Sinusotomy *

Stapedectomy *

Submucous resection *

Tonsillectomy *

Tracheostomy *

Tympanoplasty *

Oral

Closed reduction facial fractures/wiring *

Excision odontoma *

Excision of deciduous teeth *

Extraction of impacted molars *

Fractured jaws, mandibular and zygomatic *

Gingivectomy *

LeFort osteotomies *

Maxillary procedure with graft *

Pediatric dentistry *

Sagittal osteotomy *

Temporomandibular (TMJ) with arthroplasty *

TMJ exploration *

Ophthalmology

Cataract extraction with IOL *

Corneal transplant *

Eye enucleation *

Excision of chalazion *

Canthotomy *

Correction of ectropian/entropian *

Enucleation *

Eye transplant *

Iridectomy *

Lacrimal duct probing *

Lid and muscle procedures *

Orbital implant *

Phaco emulsification *

Pterygium repair *

Recession resection *

Refractive keratoplasty *

Repair orbital blowout fracture *

Repair of retinal detachment *

Scleral buckle *

Vitrectomy *

Endoscopic Procedures

Bronchoscopy *

Colonoscopy *

Culdoscopy *

Esophagoscopy *

Gastroscopy *

Hysteroscopy *

Laparoscopic Procedures

Appendectomy *

Cholecystectomy / Cholangiogram *

Colon Resection *

Diagnostic *

Hernia Repair *

Nissen Fundoplication *

Salpingo-oophorectomy *

Tubal Ligation *

Laryngoscopy and Microlaryngoscopy *

Mediastinoscopy *

Pelviscopy *

Sigmoidoscopy *

Thoracoscopy *

Transplant

Bone *

Bone Marrow *

Corneal Transplant *

Harvesting *

Heart *

Kidney *

Liver *

Lung *

Multi-organ *

Pancreas *

Skin *

Trauma

Burns *

Motor Vehicle Accidents (Multiple Injuries) *

Traumatic Amputations *

Gunshot/Stab Wounds

Abdomen *

Chest *

Head *

Equipment

Argon Beam Coagulator *

Bair Hugger *

Cell Saver *

Cidex Soak *

Cry-Ophthalmic Unit *

Defibrillator/Pacer *

Electrosurgical Unit *

Emerson Thoracic Pump *

ETO Sterilizer *

Eye Magnet *

Fiber Optic Luminator *

Flash Autoclave *

Hypo/Hyperthermia Units *

Kreiselman Resuscitor *

Mesh Graft *

Microscopes *

Nerve Stimulator *

Nitrous Oxide Bank *

Ohio Suction Units *

Orthopedic Arm Board with Drain *

Pleurevac Disp. Chest Drainage *

Pneumatic Tourniquet *

Sterad Machine *

Steri-Vac Aeration Cabinet *

Steris Unit *

Tele Thermometer *

Ultrasonic Cleaner *

Vac-Pac Positioner *

Vacuum Curettage *

Washer Sanitizer *

Washer Sterilizer *

Equipment - Fracture Tables

Chick/Marquet Tables *

Jackson Table *

Rush/Skytron Tables *

Equipment - Intestinal Stapling Devices

EEA *

GIA *

LDS *

TA *

Equipment - Laser

CO2 *

Eye Magnet *

Yag *

Other *

Camera/Video Systems

Camera Controller *

Light Source *

Printers *

VCRs *

Dermatome

Brown *

Padgett *

Zimmer *

Disposable Grounding Pads *

Drills

3-M Maxi Driver *

Codman Craniotome *

Hall Air-Driver *

Hall Dental *

Hall Neurotome *

Midax Rex/Anspach *

Minidriver *

Stryker Drills - Large Battery *

Stryker Drills - Small Battery *

Surgairtome *

Synthes A-O Drill *

Electrosurgical Unit *

Miscellaneous

Assist with Intubation *

Conscious Sedation Administration *

Conscious Sedation Monitoring *

Management of Malignant Hypertensive Crisis *

Able to Assure a Safe Environment for Various Age Groups

Newborn/Neonate (Birth - 30 Days) *

Infant (30 Days - 1 Year) *

Toddler (1 - 3 Years) *

Preschooler (3 - 5 Years) *

School Age Children (5 - 12 Years) *

Adolescents (12 - 18 Years) *

Young Adults (18 - 39 Years) *

Middle Adults (39 - 64 Years) *

Older Adults (64+) *

Able to Communicate and/or Instruct Patients According to Their Age, Maturity, Comprehension

Newborn/Neonate (Birth - 30 Days) *

Infant (30 Days - 1 Year) *

Toddler (1 - 3 Years) *

Preschooler (3 - 5 Years) *

School Age Children (5 - 12 Years) *

Adolescents (12 - 18 Years) *

Young Adults (18 - 39 Years) *

Middle Adults (39 - 64 Years) *

Older Adults (64+) *

Evaluate Age-Appropriate Behavior, Motor Skills, and Physiological Norms

Newborn/Neonate (Birth - 30 Days) *

Infant (30 Days - 1 Year) *

Toddler (1 - 3 Years) *

Preschooler (3 - 5 Years) *

School Age Children (5 - 12 Years) *

Adolescents (12 - 18 Years) *

Young Adults (18 - 39 Years) *

Middle Adults (39 - 64 Years) *

Older Adults (64+) *

Peri-Operative

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