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:

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download