Surgical Technician (ORT) Skills Checklist

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Cassandra Warren
8 years ago
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1 _ XXX-XX- Print Name Last 4 of SS # Date Completed Directions Please circle a value for each question to provide us and the interested facilities with an assessment of your clinical experience. These values confirm your strengths within your specialty and assist the facility in the selection process of the healthcare professional. 1 - No (has never done or observed) 2 - Requires Training (In-Service) - not performed within last 36 months 3 - Limited (requires assistance or training) - performed within the last 24 months 4 - d (routinely performs without assistance) - performed within the last 12 months 5 - Able to Supervise, Precept and Teach - performed within the last 6 months EQUIPMENT: NITROGEN TANK CUSA LASER EQUIPMENT CELL SAVER AUTOTRANSFUSION DRAINING AUTOCLAVE CRYO-OPTHALMIC UNIT STERIS UNIT VIDEO SYSTEMS/CAMERA PNEUMATIC TOURNIQUET ELECTROSURGICAL UNIT VENODYNE DERMATONE/MESH GRAFT FIBEROPTIC EQUIPMENT CIDEX SOAK PULSEVAC IRRIGATION MICROSCOPES Version: 07/03/2012 Page 1 out of 8

1 - No (has never done or observed) 2 - Requires Training (In-Service) - not performed within last 36 months 3 - Limited (requires assistance or training) - performed within the last 24 months 4 - d

2 EQUIPMENT: SAW / DRILLS FRACTURE TABLES FIBER OPTIC LAMINATOR STAPLING DEVICES CAVITRON CARDIOVASCULAR RIB RESECTION INTRA-AORTIC BALLOON PUMP AORTIC ANEURYSM AORTIC FEMORAL BYPASS GRAFT LOBECTOMY PACEMAKERS THORACOTOMY FEMORAL/POPLITEAL BYPASS ENDOSCOPIC VEIN HARVESTING ASV/VSD/SEPTAL DEFECTS OFF PUMP BYPASS CARDIAC CATH LAB VALVE REPLACEMENT CORONARY ARTERY BYPASS GENERAL SURGERY SPLENECTOMY BOWEL RESECTION VAGOTOMY ILEOSTOMY ORGAN PROCUREMENT TRACHEOTOMY ABDOMINAL PERINEAL RESECT HERNIORRHAPHY THYROIDECTOMY Version: 07/03/2012 Page 2 out of 8

HARVESTING 1 2 3 4 5 ASV/VSD/SEPTAL DEFECTS 1 2 3 4 5 OFF PUMP BYPASS 1 2 3 4 5 CARDIAC CATH LAB 1 2 3 4 5 VALVE REPLACEMENT 1 2 3 4 5 CORONARY ARTERY BYPASS 1 2 3 4 5 GENERAL SURGERY SPLENECTOMY 1 2

3 GENERAL SURGERY COLOSTOMY SAPHENOUS VEIN LIGATION ADRENALECTOMY MASTECTOMY CHOLANGIOGRAM PANCREATECTOMY HIATAL HERNIORRHAPHY GASTRECTOMY NEUROLOGY SHUNT PROCEDURES VP/VA/LP BURR HOLES MYLELOMENINGOCELE REPAIR CAROTID LIGATION SPINAL FUSIONS CERVICAL SYMPHATHECTOMY VENTRICULOSTOMY INSERTION OF NERVE STIMULUS LAPAROSCOPIC PROCEDURES HALO TRACTION SUBDURAL HEMATOMA LAMINECTOMY CRANIOPLASTY DISECTOMY CRANIOTOMY ENDOSCOPY LARYNGOSCOPY CULDOSCOPY TUBAL LIGATION APPENDECTOMY THORACOSCOPY Version: 07/03/2012 Page 3 out of 8

1 2 3 4 5 VENTRICULOSTOMY 1 2 3 4 5 INSERTION OF NERVE STIMULUS 1 2 3 4 5 LAPAROSCOPIC PROCEDURES 1 2 3 4 5 HALO TRACTION 1 2 3 4 5 SUBDURAL HEMATOMA 1 2 3 4 5 LAMINECTOMY 1 2 3 4 5 CRANIOPLASTY 1 2

4 ENDOSCOPY HYSTEROSCOPY PELVISCOPY COLONOSCOPY VAGINAL HYSTERECTOMY GASTROSCOPY MEDIASTINOSCOPY BRONCHOSCOPY SALPINGO-OOPHORECTOMY CYCTOSCOPY SIGMOIDOSCOPY ESOPHAGOSCOPY HERNIA REPAIR CHOLECYSTECTOMY COLON RESECTION EAR, NOSE & THROAT SEPTOPLASTY ADENOIDECTOMY THRACHEOSTOMY RADICAL NECK MASTOIDECTOMY CALDWELL-LUC SINUSOTOMY TONSILLECTOMY CLEFT LIP MANDIBULECTOMY LARYNEGECTOMY GYNECOLOGY TUBAL LIGATION ABDOMINAL HYSTERECTOMY RADIUM INSERTION Version: 07/03/2012 Page 4 out of 8

THROAT SEPTOPLASTY 1 2 3 4 5 ADENOIDECTOMY 1 2 3 4 5 THRACHEOSTOMY 1 2 3 4 5 RADICAL NECK 1 2 3 4 5 MASTOIDECTOMY 1 2 3 4 5 CALDWELL-LUC 1 2 3 4 5 SINUSOTOMY 1 2 3 4 5 TONSILLECTOMY 1 2 3 4

5 GYNECOLOGY DILATION/CURETTAGE VAGINECTOMY SHIRODKAR PROCEDURE C-SECTION LASER SURGERY TOP VAGINAL HYSTERECTOMY HYSTERECTOMY - ABDOMINAL HYSTERECTOMY - VAGINAL OPTHAMOLOGY RETINAL DETACHMENT CORNEAL TRANSPLANT CATARACT EXTRACTION ENUCLEATION SCLERAL BUCKLE IOL IMPLANTS ORBITAL IMPLANTS ORBITAL FRACTURES ORTHOPEDIC DISLOCATION REPAIRS ARTHOTOMY TOTAL JOINT REPLACEMENTS ACHILLES TENDON REPAIR PATELLECTOMY EXTERNAL COMPRESSIONS ORIF AMPUTATION SPICA CAST REDUCTION OF EXTREMITIES TENDON IMPLANTS Version: 07/03/2012 Page 5 out of 8

IOL IMPLANTS 1 2 3 4 5 ORBITAL IMPLANTS 1 2 3 4 5 ORBITAL FRACTURES 1 2 3 4 5 ORTHOPEDIC DISLOCATION REPAIRS 1 2 3 4 5 ARTHOTOMY 1 2 3 4 5 TOTAL JOINT REPLACEMENTS 1 2 3 4 5 ACHILLES TENDON REPAIR 1

6 ORTHOPEDIC ARTHROSCOPY HIP COMPRESSION NAILS TRANSPLANTS MULTI ORGANS BONE MARROW HEART/LUNG SKIN CORNEAL LIVER PANCREAS KIDNEY BONE HARVESTING UROLOGY HYPOSPADIUS REPAIR LITHOTRIPSY PROSTATACTOMY URETEROSCOPY URETEROLITHOMY CIRCUMCISION ORCHIECTOMY VASECTOMY CYSTOSCOPY NEPHRECTOMY IMPLANTS CYSTECTOMY VASCULAR EMBOLECTOMY AORTIC ANEURYSM THROMBECTOMY Version: 07/03/2012 Page 6 out of 8

PROSTATACTOMY 1 2 3 4 5 URETEROSCOPY 1 2 3 4 5 URETEROLITHOMY 1 2 3 4 5 CIRCUMCISION 1 2 3 4 5 ORCHIECTOMY 1 2 3 4 5 VASECTOMY 1 2 3 4 5 CYSTOSCOPY 1 2 3 4 5

7 VASCULAR ANGIOGRAPHY AORTIC ENDARTERECTOMY PERIPHERAL VASCULAR BYPASS VENA CAVA LIGATION CAROTID ANEURYSM/GRAFT PLASTICS OTOPLASTY FACE LIFT REDUCTION ADBOMINAL LIPECTOMY SKIN GRAFTING BREAST AUGMENTATION SCAR REVISIONS BLEPHAROPLASTY LIPOSUCTION MAMMOPLASTY RECONSTRUCTION TRAUMA MVA'S BURNS STAB WOUNDS TRAUMATIC AMPUTATIONS GUNSHOT WOUNDS JUMPERS DRUG OVERDOSE LEVEL 1 TRAUMA IN PATIENT HOSPITAL OUT PATIENT SETTING AGE APPROPRIATE CARE NEWBORN (BIRTH-30 DAYS) Version: 07/03/2012 Page 7 out of 8

4 5 MAMMOPLASTY 1 2 3 4 5 RECONSTRUCTION 1 2 3 4 5 TRAUMA MVA'S 1 2 3 4 5 BURNS 1 2 3 4 5 STAB WOUNDS 1 2 3 4 5 TRAUMATIC AMPUTATIONS 1 2 3 4 5 GUNSHOT WOUNDS 1 2 3 4 5 JUMPERS 1 2 3 4 5 DRUG

8 AGE APPROPRIATE CARE INFANT (30 DAYS - 1 YEAR) TODDLER (1-3 YEARS) PRESCHOOLER (3-5 YEARS) SCHOOL AGE (5-12 YEARS) ADOLESCENTS (12-18 YEARS) YOUNG ADULTS (18-39 YEARS) MIDDLE ADULTS (39-64 YEARS) OLDER ADULTS (64+ YEARS) The information represented above is true and correct to the best of my knowledge. I also authorize Specialty Professional Services, Corp to share the above skills checklist with its facility clients. Signature Date Completed Fax: Version: 07/03/2012 Page 8 out of 8

YEARS) 1 2 3 4 5 The information represented above is true and correct to the best of my knowledge.

SURGICAL TECHNICIAN JOB DESCRIPTION

SURGICAL TECHNICIAN JOB DESCRIPTION PERIOPERATIVE CARE Job Summary: The Surgical Technician performs the scrubbing duties for operative procedures and assists the Registered Nurse Circulator, as directed.