Surgical Technician Skills Checklist Form | Professional Nursing Service

Items in red are REQUIRED fields.
Personal Information:
First Name:	Middle Initial:
Last Name:
Address:
City:
State:	ZIP:
Phone:
E-mail Address:
Years of Experience:
Directions for completing Skills Checklist:
The following is a list of equipment and/or procedures performed in rendering care to patients. Please indicate the level of experience/proficiency with each and, where applicable, the types of equipment and/or systems with which you are familiar. Use the following KEY as a guideline:
A) Theory Only/No Experience - Didactic instruction only, no hands-on experience. B) Limited Experience - Knows procedure/has used equipment, but has done so infrequently or not within the last six months. C) Moderate Experience - Able to demonstrate equipment/procedure, performs the task/skill independently with only resource assistance needed. D) Proficient/Competent - Able to demonstrate/perform the task/skill proficiently without any assistance and can instruct/teach.

A. EAR, NOSE, & THROAT	A B C D
1. Adenoidectomy
2. Caldwell - Luc
3. Cleft lip/palate repair
4. Closed reduction nasal fracture
5. Ethmoidectomy
6. Excision of salivary gland tumor
7. Fenestration procedure
8. Frontal flap sinus procedure
9. Glossectomy
10. Laryngectomy
11. Mandibulectomy
12. Mastoidectomy
13. Maxillary advancement with hip graft
14. Maxillectomy
15. Myringoplasty
16. Myringotomy/with PE tube insertion
17. Nasal polypectomy
18. Open reduction facial fracture
19. Open reduction nasal fracture
20. Parotidectomy
21. Pharyngeal flap procedure
22. Radical neck dissection
23. Ranulectomy
24. Rhinoplasty/septoplasty
25. Selective osteotomy of maxilla/mandible
26. Sinus endoscopy
27. Sinusotomy
28. Stapedectomy
29. Submucous resection
30. Tonsillectomy
31. Tracheostomy
32. Tympanoplasty

B. ENDOSCOPIC PROCEDURES	A B C D
1. Bronchoscopy
2. Colonoscopy
3. Culdoscopy
4. Cytoscopy
5. Esophagoscopy
6. Gastroscopy
7. Hysteroscopy
8. Laparoscopic procedures
(a) Appendectomy
(b) Cholecytectomy/cholangiogram
(c) Colon resection
(d) Hernia repair
(e) Nissen fundoplication
(f) Salpingo-oophorectomy
(g) Tubal ligation
(h) Vaginal hysterectomy
9. Laryngoscopy & microlaryngoscopy
10. Mediastinoscopy
11. Pelviscopy
12. Sigmoidoscopy
13. Thoracoscopy

C. GENERAL SURGERY	A B C D
1. Abdominal perineal resection
2. Adrenalectomy
3. Anal fissurectomy
4. Appendectomy
5. Breast biopsy
6. Colectomy
7. Colostomy/ileostomy
8. Gastrectomy
9. Gastroplasty
10. Hemmorhoidectomy
11. Hepatic resection
12. Herniorrhaphy - femoral, inguinal, umbilical
13. Hiatal herniorrhaphy, transabdominal/transthoracic
14. Hickman/Groshong/Portacath insertion
15. Hydrocelectomy
16. Imperforate anus reconstruction
17. Lumbal sympathectomy
18. Omphalocele repair
19. Pancreatectomy
20. Pilonidal cystectomy
21. Portal caval shunt
22. Pyloric stenosis
23. Radical mastectomy
24. Saphenous vein ligation and stripping
25. Sentinel node biopsy
26. Splenectomy
27. Tenchkhoff catheter placement
28. Thyroglossal duct cyst excision
29. Thyroidectomy
30. Tracheostomy
31. Vagotomy

D. GYNECOLOGY	A B C D
1. Cesarean section
2. Colpotomy
3. Dilation and curettage (D&C)
4. Hysterectomy, abdominal
5. Hysterectomy, vaginal
6. Marshall - Marchetti
7. Marsupialization, Bartholin cyst
8. Ovarian cystectomy
9. Radium insertion
10. Sacral spinus fixation
11. Shirodkar procedure
12. Suction curratege
13. Vaginal reconstruction
14. Vaginectomy/vulvectomy

E. NEUROLOGY	A B C D
1. A-V malformation
2. Anterial cervical fusion
3. Anterior laparoscopic spine procedures
4. Anterior lumbar interbody fusion (ALIF)
5. Burr holes for subdural hematoma
6. Carotid ligation
7. Cervical sympathectomy
8. Craniectomy for decompression fracture
9. Cranioplasty/craniotomy
(a) Clipping of aneurysm
(b) Tumor excision using stealth equipment (stealth craniotomy)
10. Discectomy
11. Hypophysectomy
12. Insertion nerve stimulators/medication pumps
13. Laminectomy
14. Myelomeningocele repair
15. Pedicle screw insertion
16. Posterior lumbar interbody fusion (PLIF)
17. Shunt procedure/VP, VA/LP
18. Spine fusion - list systems you have used
19. Ulnar nerve transfer
20. Ventricularography procedure/ventriculoscopy
21. Ventriculostomy

F. OPTHALMOLOGY	A B C D
1. Cataract extraction with IOL
2. Corneal transplant
3. Dacryocystectomy
4. Dacryocystorhinostomy
5. Iridectomy
6. Lid and muscle procedures
7. Orbital implant
8. Phaco emulsification
9. Pterygium repair
10. Recession resection
11. Repair orbital blowout fracture
12. Scleral buckle
13. Vitrectomy

G. ORAL	A B C D
1. Closed reduction facial fractures/wiring
2. Excision odontoma
3. Extraction of deciduous teeth
4. Extraction of impacted molars
5. Fractured jaws, mandibular and zagomatic
6. LeFort osteotomies
7. Maxillary procedure with graft
8. Pediatric dentistry
9. Sagittal osteotomy
10. Temporomandibular joint (TMJ) with arthroplasty
11. TMJ exploration

H. ORTHOPEDICS	A B C D
1. Acetabular/pelvic ORIF
2. Achilles tendon repair
3. Amputation - leg, arm
4. Anterior cruciate ligament repair
5. Application of external fixators
(a) Extremeties
(b) Pelvis
6. Application of halo traction
7. Arthroscopy
(a) Ankle
(b) Elbow
(c) Knee
(d) Shoulder
8. Arthrotomy
9. Bipolar/unipolar hips
10. Bunionectomy
11. Calcaneal reconstruction
12. Capsulorrhaphy
13. Carpal tunnel release
14. Closed reduction fracture
15. Hand surgery with implants
16. Harrington rod instrument and/or Dwyer procedure
17. Heel cord lengthening
18. Hip compression nails & lag screws
(a) Jewett
(b) Kuntscher rod
(c) Lottes
(d) Rush
(e)Schneider
(f) Zimmer
(g) Others - list
19. Iliac crest bone graft
20. Insertion Austin Moor hip prosthesis
21. Intramedullary rods
(a) Extraction
(b) Femoral
(c) Humeral
(d) Insertion
(e) Supracondylar
(f) Tibial