OPERATING ROOM KNOWLEDGE & SKILLS CHECKLIST

DIRECTIONS: Please indicate your level of experience by

NAME:       placing a check (√) in the box. Experience level:
ID #:       1 NO EXPERIENCE
DATE:       2 MINIMAL EXPERIENCE-requires supervision/assistance
3 MODERATELY EXPERIENCED-requires initial review,
This Skills Checklist is for use by nurses with more than then performs independently
one year experience in their discipline and specialty. 4 VERY EXPERIENCED- proficient
Please be accurate with your assessment.

DESCRIPTION 1 2 3 4
DESCRIPTION 1 2 3 4 5. Sinus Endoscopy
NEUROLOGY 6. Stapedectomy
1. Acoustic Neuromas 7. T & A Myringotomies
2. Aneurysm Repair 8. Tracheostomy
3. Cervical Laminectomy 9. Tympanoplasty
4. Craniotomy 10. Vocal Cord Stripping
5. Endarterectomy GENERAL
6. Hematoma Evacuation 1. Abdominal Resection
7. Lumbar Laminectomy 2. Appendectomy
8. Neuro Trauma 3. Cholecystectomy
9. Shunts 4. Colon Resection
EYE 5. Colostomy
1. Blepharoplasty 6. Gastrectomy
2. Cataract with IOL 7. Hernia Repair
3. Chalazion 8. Lap Chole
4. Corneal Transplant 9. Laparotomy
5. Dacryocystorhinoplasty 10. Mastectomy
6. Enucleation 11. Thyroidectomy
7. Iridectomy THORACIC/OPEN HEART
8. Muscle Repair 1. Atrial Septal Defect
9. Removal Foreign Body 2. Bronchoscopy
10. Retinal Detachment Repair 3. CABG
11. Trabeculectomy 4. Internal Defibrillator
ORAL 5. Mediastinoscopy
1. Grafts 6. Pacemaker Insertion
2. Letorte Osteotomies 7. Pneumonectomy
3. Mandibular Procedures 8. Thoracotomy
4. Maxillary Procedures 9. Valve Replacement
5. TMJ Arthroplasty 10. Ventricular Septic Defect
EAR, NOSE, THROAT VASCULAR
1. Laryngectomy 1. Aortic Aneurysm
2. Mastoidectomy 2. Embolectomy
3. Radical Neck 3. Fem-Fem Bypass
4. Septoplasty 4. Fem-Pop Bypass
5. Fem-Tib Bypass

1|Page
 OPERATING ROOM KNOWLEDGE & SKILLS CHECKLIST

Name:       ID #:      

DESCRIPTION 1 2 3 4 DESCRIPTION 1 2 3 4
6. Vein Ligation 2. MVA
7. Carotid Endarterectomy 3. Traumatic Amputations
UROLOGY TRANSPLANTS
1. Archiotomy 1. Harvest Organs
2. Cystoscopy 2. Heart
3. Nephrectomy 3. Kidney
4. Penile Prosthesis 4. Liver
5. Radical Prostate Resection 5. Lung
6. TURP PEDIATRICS
7. Ureterolithotomy 1. Abdominal Procedures
8. Urinary Diversion 2. Neonatal Procedures
ORTHOPEDICS 3. Open Heart
1. Amputation 4. Orthopedic Procedures
2. Arthroscopy 5. Plastics
3. Bunionectomy 6. Thoracotomy
4. Carpal Tunnel Release EQUIPMENT
5. Closed Reduction 1. Ceiling Mount Microscope
6. Hip pinning 2. Doppler
7. ORIF 3. Electrosurgery Unit
8. Spinal Rodding/Fixation 4. Endoscopy Scopes
9. Total Joint Replacement 5. Fracture Table
10. Hip Replacement 6. High Flow Insuflator
11. Knee Replacement 7. Intra Aortic Balloon Pump
12. Shoulder Replacement 8. Laser
13. Hand Surgery 9. Nerve Stimulators
GYNECOLOGY 10. Pacemakers
1. A&P Repair 11. Portable Microscope
2. Laparoscopy 12. Ventilators
3. Vaginal Hysterectomy 13. Anesthesia Equipment
4. Abdominal Hysterectomy 14. Cardiac Monitors
5. C-Section 15. Infusion Pumps
6. Marshall Marchetti 16. Drills/Saws
7. Tubal Ligation 17. Tourniquet
PLASTICS 18. Midas Rex
1. Abdominoplasty COMPUTERIZED CHARTING
2. Breast Reconstruction 1. Cerner
3. Cleft Lip/Palate 2. Eclipsys
4. Flap Grafts 3. Epic
5. Mammoplasty 4. McKesson
6. Rhinoplasty 5. Meditech
TRAUMA 6. Other:
1. Gunshot Wounds

2|Page
 OPERATING ROOM KNOWLEDGE & SKILLS CHECKLIST

Name:       ID #:      

Please check the boxes below for each age group for I HAVE CURRENT CERTIFICATIONS FOR:
which you have expertise in providing age-appropriate
nursing care. TYPE COURSE DATE (MM/DD/YY)
ARRHYTHMIA      
A. Newborn/Neonatal (birth – 30 days) CRITICAL CARE      
B. Infant (30 days – 1 year) ACLS      
C. Toddler (1 – 3 years) BCLS      
D. Preschool (3 – 5 years) TNCC      
E. School Age Children (5 – 12 years) NRP      
F. Adolescent (12 – 18 years) PALS      
G. Young Adults (18 – 39 years) NALS      
H. Middles Adults (40 – 64 years) BTLS      
I. Older Adults (64 + years) CCRN      
Other            
EXPERIENCE WITH AGE GROUPS: Other            
1. Able to assess age appropriate behavior, motor skills
and physiological norms.
The information I have provided in this knowledge and
A B C D E F G H I skills checklist it true and accurate to the best of my
knowledge.

2. Able to adapt care according to normal growth and            

development. Signature (Written/Electronic) Date
ID #:      
A B C D E F G H I
This skills checklist has been reviewed and approved by
Nicole Bloxham, RN.
3. Able to communicate and instruct patient according to
their age, maturity and comprehension ability.            
Signature (Written/Electronic) Date
A B C D E F G H I ID #:      

4. Able to provide a safe environment according to the Please return to: Northwest Nurse Staffing Company, PA
specific needs of various age groups. ATTN: Records Dept.
Fax: (866) 352-4338
A B C D E F G H I Email: records@nns-ic.com

3|Page