NORTHWEST NURSE STAFFING



NAME: FORMTEXT ?????ID #: FORMTEXT ?????DATE: FORMTEXT ?????This Skills Checklist is for use by nurses with more than one year experience in their discipline and specialty. Please be accurate with your assessment.DIRECTIONS: Please indicate your level of experience by placing a check (√) in the box. Experience level: 1NO EXPERIENCE2MINIMAL EXPERIENCE-requires supervision/assistance3MODERATELY EXPERIENCED-requires initial review, then performs independently4VERY EXPERIENCED- proficientDESCRIPTION1234GENERAL SURGERY: 1. Abdominal Resection FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 2. Adrenal Biopsy FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 3. Anal Fissurectomy FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 4. Appendectomy FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 5. Breast Biopsy FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 6. Colectomy FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 7. Cholecystectomy FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 8. Colon Resection FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 9. Colostomy FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 10. Femoral Herniorrhaphy FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 11. Gastrectomy FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 12. Hemorrhoidectomy FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 13. Hernia Repair FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 14. Hepatic Resection FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 15. Hiatal Herniorrhaphy FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 16. Hydrocelectomy FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 17. Inguinal Herniorrhaphy FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 18. Lap Chole FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 19. Laparotomy FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 20. Lumbar Sympathectomy FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 21. Mastectomy FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 22. Pancreatectomy FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 23. Pilonidal Cystectomy FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 24. Portal Caval Shunt FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 25. Pyloric Stenosis FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 26. Radical Mastectomy FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 27. Saphenous Vein Ligation FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX DESCRIPTION123428. Splenectomy FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 29. Thyroidectomy FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 30. Tracheostomy FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 31. Vagotomy FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX GYNECOLOGY: 1. Abdominal Hysterectomy FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 2. A&P Repair FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 3. Cesarean Section FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 4. Colposcopy FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 5. Colpotomy FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 6. Dilation & Curettage FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 7. Laparoscopy FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 8. Marshall Marchetti FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 9. Radium Insertion FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 10. Sacral Spinus Fixation FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 11. Salpingoplasty FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 12. Shirodkar Operation FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 13. Suction Curettage FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 14. Tuboplasty FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 15. Tubal Ligation FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 16. Vaginal Hysterectomy FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 17. Vaginal Reconstruction FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX ENDOSCOPIC: 1. Bronchoscopy FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 2. Colonoscopy FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 3. Cystoscopy FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 4. Culdoscopy FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 5. Esophagoscopy FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 6. Gastroscopy FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 7. Laryngoscopy FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 8. Pelviscopy FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 9. Sigmoidoscopy FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 10. Thoracoscope FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX ENT: 1. Adenoidectomy FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 2. Caldwell_LUC Operation FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 3. Closed Reduction Nasal FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 4. Fenestration Procedure FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 5. Glossectomy FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 6. Laryngectomy FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 7. Mandibulectomy FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 8. Mastoidectomy FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 9. Myringotomy FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX NAME: FORMTEXT ?????ID #: FORMTEXT ?????DATE: FORMTEXT ?????ENT (CONT):DESCRIPTION123410. Parotidectomy FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 11. Pharyngeal Flap Procedure FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 12. Radical Neck Dissection FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 13. Rhinoplasty/Septoplasty FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 14. Sinusotomy FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 15. Stapendectomy FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 16. Submucous Resection FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 17. Tonsillectomy FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 18. Tracheostomy FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 19. Tympanoplasty FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX NEURO: 1. A-V Malfunction FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 2. Anterior Cervical Fusion FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 3. Carotid Ligation FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 4. Cervical Sympathectomy FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 5. Clipping of Aneurysm FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 6. Cranioplasty/Craniotomy FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 7. Decompressive Craniectomy FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 8. Discectomy FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 9. Hypophysectomy FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 10. Laminectomy FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 11. Myelomeningocele Rep. FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 12. Pedicle Screw Insertion FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 13. Shunt Procedure FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 14. Spinal Fusion FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 15. Tumor Excision FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 16. Ulnar Nerve Transfer FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 17. Ventriculography FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 18. Ventriculostomy FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX ORAL: 1. Closed Reduction Facial Fractures FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 2. Excision Odontoma FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 3. Extraction of Deciduous Teeth FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 4. Extraction of Impacted Molars FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 5. Fractured Jaw FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 6. LeFort Osteotomies FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 7. Mandiblectomy FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX DESCRIPTION1234 8. Maxillary Procedures FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 9. Pediatric Dentistry FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 10. Sagittal Osteotomy FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 11. TMJ exploration FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 12. TMJ w/Arthroplasty FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX OPTHALMOLOGY: 1. Cataract Extraction FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 2. Corneal transplant FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 3. Dacryocystectomy FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 4. Iridectomy FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 5. Orbital Implant FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 6. Pterygium Repair FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 7. Recession Resection FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 8. Scleral Buckle FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX ORTHOPEDIC: 1. Acetabular/Pelvic ORIF FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 2. Achilles Tendon Repair FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 3. ACL Repair FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 4. Amputation FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 5. Arthrotomy FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 6. Bone Graft FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 7. Bunionectomy FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 8. Calcaneal Reconstruction FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 9. Capsulorrhaphy FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 10. Carpal Tunnel Release FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 11. Cup Arthroplasty FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 12. Hand Surgery FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 13. Heel Cord Lengthening FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 14. Hip Prosthesis FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 15. Laminectomy FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 16. Patellectomy FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 17. Reimplantation of Digits FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 18. Repair Hammer Toes FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 19. Rotator Cuff Repair FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 20. Sacro-Illiac Joint Screws FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 21. Sharrard Procedure FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 22. Spinal Fusion FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 23. Tendon Transplant FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 24. Total Joint Replacement FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX PEDIATRIC: 1. Broviac FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 2. ECMO Cannulation FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 3. Gastrosclesis FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 4. Myelomeningocele Repair FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX NAME: FORMTEXT ?????ID #: FORMTEXT ?????DATE: FORMTEXT ?????PEDIATRIC (CONT):DESCRIPTION1234 5. Omphalocele FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 6. Open Heart FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 7. Pyloric Stenosis Repair FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 8. Repair of TEF FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX PLASTICS 1. Abdominal Lipectomy FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 2. Augumentation FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 3. Blepharoplasty FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 4. Cleft Lip FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 5. Dermabrasion FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 6. Face Lift FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 7. Mammoplasty FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 8. Mentoplasty FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 9. Otoplasty FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 10. Pedicle Grafts FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 11. Reconstructive FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 12. Reduction FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 13. Rhinoplasty FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 14. Scar Revisions FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 15. Skin Grafting FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 16. Tissue Expanders FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX THORACIC/OPEN HEART 1. Aortic Valve Replacement FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 2. Cervical Rib Excision FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 3. Chamberlain Procedures FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 4. Closed Thoracotomy FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 5. Esophagectomy FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 6. Heller Procedure FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 7. Mitral Commissurotomy FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 8. Mitral Valve Replacement FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 9. Open Heart FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 10. Pacemaker Implant FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 11. Patent Ductus Arteriosus FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 12. Pericardiectomy FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 13. Rib Resection FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 14. Septal Defect Repairs FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 15. Tetralogy of Fallot FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 16. Thoracoplasty FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX DESCRIPTION123417. Tracheal Resection FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX UROLOGY: 1. Circumcision FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 2. Cystectomy FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 3. Lithotripsy FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 4. Nephrectomy FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 5. Orchiopexy FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 6. Penile Implants FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 7. Prostatectomy FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 8. Pyeloplasty FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 9. Radical Node Dissection FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 10. Scott Incontinence Device FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 11. TURP FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 12. Ureterolithotomy FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 13. Vasectomy FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 14. Vasovasostomy FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 15. Waterhouse Procedure FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX VASCULAR: 1. Aortic Aneurysm w/Graft FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 2. A-V Access Graft FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 3. Carotid Aneurysm FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 4. Endarterectomy Peripheral FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 5. Thrombectomy Resection FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 6. Vascular Bypass Resection FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 7. Vena Cava Filter FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 8. Vena Cava Ligation FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX EQUIPMENT: 1. Anesthesia Equipment FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 2. Arthroscopy Cameras FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 3. Blood Warmer FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 4. Cardiac Monitors FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 5. Doppler Drills/Saws Cell Saver FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 6. Electrosurgery Unit FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 7. Endoscopy Scopes FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 8. Fluid Pumps Eye Magnet FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 9. Fracture Table FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 10. Intra Aortic Balloon Pump FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 11. Infusion Pumps FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 12. Microscope Pacemakers FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 13. Midas Rex Laser FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 14. Nerve Stimulators FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 15. Nitrous Oxide Bank FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 16. Tourniquet Portable FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX NAME: FORMTEXT ?????ID #: FORMTEXT ?????DATE: FORMTEXT ?????EQUIPMENT (CONT):DESCRIPTION123417. Ultrasonic Cleaners FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 18. Ventilators FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX COMPUTERIZED CHARTING 1. Cerner FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 2. Eclipsys FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 3. Epic FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 4. McKesson FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 5. Meditech FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 6. Other: FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX I HAVE CURRENT CERTIFICATIONS FOR:TYPE EXPIRATION DATE (MM/DD/YY)ARRHYTHMIA FORMTEXT ?????CRITICAL CARE FORMTEXT ?????ACLS FORMTEXT ?????BLS FORMTEXT ?????TNCC FORMTEXT ?????NRP FORMTEXT ?????PALS FORMTEXT ?????NALS FORMTEXT ?????CCRN FORMTEXT ?????Other FORMTEXT ????? FORMTEXT ?????Other FORMTEXT ????? FORMTEXT ?????The information I have provided in this knowledge and skills checklist it true and accurate to the best of my knowledge. FORMTEXT ????? FORMTEXT ?????Signature (Written/Electronic)DateID #: FORMTEXT ?????This skills checklist has been reviewed and approved by Nicole Bloxham, RN. FORMTEXT ????? FORMTEXT ?????Signature (Written/Electronic)DateID #: FORMTEXT ?????Please return to: Northwest Nurse Staffing Company, PA ATTN: Records Dept. Fax: (888) 936-8383 Email: records@ ................
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