Name:
Name: Date: RN / Tech
Level of Experience: 0= Never Done, 1= Perform Under Supervision, 2= Perform Independently
|GENERAL SURGERY |Scrub |Circ. |EQUIPMENT |Scrub |Circ. |
|Breast Biopsies | | |Cardiac Monitor & Pacemaker | | |
| | | |Types: | | |
|Perineal Resection | | |Arthroscopy Cameras | | |
|Anal Fissurectomy | | |Laser | | |
|Mastectomy | | |Water Sterilizer | | |
|Radical Mastectomy | | |Bovie Electrosurgical Kit | | |
|Bowel Resection | | |Aquamatic K Thermia Unit | | |
|Colostomy / Ileostomy | | |Cell Saver | | |
|Adreanalectomy | | |Eye Magnet | | |
|Appendectomy | | |Kiddie Pneumatic Tourniquet | | |
|Gastroectomy | | |Flash autoclave | | |
|Clectomy | | |Disposable Bovie Plates | | |
|Hepatic Resection | | |Fiber Optic Luminators | | |
|Whipple | | |Ultra Sonic Cleaner | | |
| | | |Types; | | |
|Hydrocelectomy | | |Vac-Pac Positioner | | |
|Laparoscopy – Diagnostic | | |Steri-Vac Aeration Cabinet | | |
|Lap Cole | | |Fluid Pumps | | |
|Lap AP | | |Ethylene Oxide Sterilzer | | |
|Lap Hernia | | |Nerve Stimulator | | |
|Leveen –Peritonela Shunt | | |Operating Microscope | | |
|Pilonidal Cystectomy | | |Dermatomes | | |
|Lumbar Sympathectomy | | |Drills | | |
|Nissesn Fundoplication | | |Vacuum Curettage | | |
|Portal Caval Shunt | | |Other: (Please List): | | |
|Pancreatectomy | | | | | |
|Splenectomy | | | | | |
|Staging Laporotomy | | | | | |
|Thyroglossal Duct Cyst Excision | | | | | |
Pg. 1
Name: Date: RN / Tech
Level of Experience: 0= Never Done, 1= Perform Under Supervision, 2= Perform Independently
|EAR, NOSE and THROAT |Scrub |Circ. |GYNECOLOGY |Scrub |Circ. |
|Tonsillectomy | | |Cone Biopsy | | |
|Adenoidectomy | | |Operative Hysterectomy | | |
|Laryngectomy | | |Operative Laparoscopy | | |
|Tracheostomy | | |Diagnostic Hysterectomy | | |
|Vocal Cord Stripping | | |Vaginal Hysterectomy | | |
|Ethymoidectomy | | |Endometrial Ablation | | |
|Fenestration Procedure | | |Pubo Vaginal Sling | | |
|Mastoidectomy | | |LAVH | | |
|Myringotomy | | |Colpotomy | | |
|Stapedectomy | | |Salpingoplast | | |
|Tympanoplasty | | |Vaginal Reconstruction | | |
|Nasal polypectomy | | |Shirodkar Operation | | |
|Glossectomy | | |C-Sections | | |
|Frontal Flap Sinus Procedure | | |Radium Insertion | | |
|Pharyngeal Flap Procedure | | | | | |
|Parotidectomy | | |NEUROLOGY | | |
|Maxillary Advancement with Hip Graft | | |Burr Holes | | |
|Open Reduction Facial Fractures | | |Lumbar and Cervical Laminectomy | | |
|Open Reduction Tripod Fractures | | |Cartoid Endarterectomy | | |
|Ranulectomy | | |Cartoid Ligation | | |
|PE Tube Insertion | | |Craniotomy for Subdural Hematoma | | |
|Radical Neck Dissection | | |Craniotomy for Tumor excision | | |
|Selective Osteotomy of Maxilla / Mandible | | |Clipping for Intracranial Aneurysm | | |
|Submucous Resection | | |Meningocele Repair | | |
|Other: (Please list): | | |VA & VP Shunt | | |
| | | |Shunts | | |
| | | |Transphenoid Hypothypectomy | | |
Pg. 2
Name: Date: RN / Tech
Level of Experience: 0= Never Done, 1= Perform Under Supervision, 2= Perform Independently
|NEUROLOGY CON’TD. |Scrub |Circ. |ORTHOPEDICS CONT’D. |Scrub |Circ. |
|Vinke Tong Insertion | | |Capsularrhaphy | | |
|Other (Please List): | | |Anterior Crucidate Ligament Repair | | |
| | | |Harrington Rod Insertion | | |
| | | |I.M. Rodding | | |
| | | |Open Reduction Fracture | | |
|OPHTHALMOLOGY | | |Closed Reduction Fracture | | |
|Chelazion | | |Fracture Table Use | | |
|Cataract | | |Dwyer Anterior Fusion | | |
|Lacrimal Probing | | |Hand Surgery with Implants | | |
|IOL Glaucoma Filtering Procedures | | |Insertion of Swanson Finger Prosthesis | | |
|Retinal Surgery | | |Tendon Implants | | |
|Corneal Transplant | | |Heel Cord Lengthening | | |
|Other (Please List): | | |Insertion of Tibial Plateau Prostheses | | |
| | | |Patellectomy | | |
| | | |ACL / PCL | | |
| | | |Instrumented Spines | | |
|ORTHOPEDICS | | |Zimmer Hip Compression | | |
|Dupuytrens | | |Nailing Procedures | | |
|I & D | | |Excision of Olecranon Bursa | | |
|Amputation Arm / Leg | | |Other (Please List): | | |
|Achilles Tendon Repair | | | | | |
|Application of Halo Traction | | | | | |
|ORIF with Plates and Screws | | |OPEN HEART / THORACIC | | |
|Hemiarthropsy | | |Cervical Rib Excision | | |
|Cup Arthroplasty | | |Closed Thoracotomy | | |
|Total Joint Replacement | | |Esopagectomy | | |
Pg. 3
Name: Date: RN / Tech
Level of Experience: 0= Never Done, 1= Perform Under Supervision, 2= Perform Independently
|OPEN HEART / THORACIC CONT’D. |Scrub |Circ. |VASCULAR |Scrub |Circ. |
|Heller Procedure | | |A-V Fistula Shunt | | |
|Valve replacement | | |Pacemaker Insertion | | |
|Pacemaker Implantation Myocardial | | |Arterial Bypass Grafts | | |
|Pacemaker Implantation Endocardial | | |Aortic Aneurysm | | |
|Port – A – Cath Insertion | | |AAA | | |
|Patent Ductus Arteiosus | | |Mohin-Uddin Umbrella | | |
|ASD (Atrial Septal defect) | | |Resection of Carotid Aneurysm with Graft | | |
|VSD ( Ventricular / Ventral Septal defect) | | |Tenkhoff Catheter Placement | | |
|Pneumonectomy (Lobectomy) | | |Embolectomy / Thrombectomy | | |
|Tracheal Resection | | |Leaking Ruptured Aneurysm | | |
|Resection of Coarctation Aorta | | |Vena Cava Ligatio | | |
|First Rib Resection | | |Other (Please List): | | |
| | | | | | |
| | | | | | |
| | | |PLASTICS | | |
|Kidney | | |Abdominal Lipectomy | | |
|Heart | | |Liposuction | | |
|Liver | | |Breast Augmentation | | |
|Lung | | |Breast Reduction | | |
|TRAUMA | | |Scar Revisions | | |
|Gun Shot Wounds: Chest | | |Myelomeningocele Repair | | |
| Abdomen | | |Mentoplasty | | |
|Burns | | |Blepheroplasty | | |
|Automobile Accidents | | |Rhinoplasty | | |
|Traumatic Amputations | | |Otoplasty | | |
| | | | | | |
Pg. 4
Name: Date: RN / Tech
Level of Experience: 0= Never Done, 1= Perform Under Supervision, 2= Perform Independently
|UROLOGY |Scrub |Circ. |Ages of Patients Cared For |Scrub |Circ. |
|Diagnostic Cystoscopy | | |Children (aged 4 – 12 years ) | | |
|Hydrocele / Variocele | | |Adolescents (aged 13- 20 years ) | | |
|Cystectomy | | |Young Adults (aged 21 – 39 years ) | | |
|Nephrectomy | | |Older Adults (aged 41 – 64 years ) | | |
|Perineal Prostatectomy | | |Seniors ( over 64 years) | | |
|Suprapubic prostatectomy | | | | | |
|Pyleoplasty | | | | | |
|Pyelolithotomy | | | | | |
|Penile Prosthesis | | | | | |
|Radical Node Dissection | | | | | |
|Ureteroscopy | | | | | |
|TUR | | | | | |
|Prostate Brachytherapy | | | | | |
|Holmium Laser Lithotripsy | | | | | |
|Indigo Laser Lithotripsy | | | | | |
|Vasectomy | | | | | |
|Vasovasotomy | | | | | |
|Ileo conduit | | | | | |
|Other (Please List): | | | | | |
| | | | | | |
| | | | | | |
| | | | | | |
| | | | | | |
| | | | | | |
I hereby certify the above to be true and accurate.
Signature: Date:
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