CVOR RN Skills Checklist Personal InformationName(Required) First Middle Last Last 4 Digits of Social Security NumberEmail(Required) Date Proficiency Scale1 – No Experience 2 – Need Training 3 – Able to perform with supervision 4 – Able to perform independentlyScrub General SurgeryAKA/BKA (Amputation) 1 2 3 4 Radical Mastectomy 1 2 3 4 Abdominal - Perineal Resection 1 2 3 4 Cholecystectomy (Open) 1 2 3 4 Exploratory Laparatomy 1 2 3 4 Appendectomy 1 2 3 4 Scrub CardiacDaVinci Procedures 1 2 3 4 Coronary Artery By-Pass 1 2 3 4 Mitral Valve Repair/Replacement 1 2 3 4 Aortic Valve Replacement 1 2 3 4 Multiple Valve Transposition 1 2 3 4 Septal Defects 1 2 3 4 Ventricular Aneurysm Repair 1 2 3 4 Bring Back Heart 1 2 3 4 Pericardial Window 1 2 3 4 Intra-Aortic Balloon Insertion 1 2 3 4 Heartport or Similar CABG 1 2 3 4 Thoraco Approach Mid-Cab 1 2 3 4 Aortic Arch Replacement 1 2 3 4 Aortic Valve Conduit 1 2 3 4 Mechanical Heart/LVAD 1 2 3 4 Pediatric Hearts 1 2 3 4 Tetrology of Fallot 1 2 3 4 Chamberlain Procedure 1 2 3 4 Femoral Artery Cannulation 1 2 3 4 AICD Insertion 1 2 3 4 Saphenous Vein Harvest 1 2 3 4 Endoscopic Vein Harvest 1 2 3 4 Gastric Artery Harvest 1 2 3 4 Radial Vein Harvest 1 2 3 4 Carotid Endarterectomy 1 2 3 4 Abdominal Aortic Aneurysm 1 2 3 4 Femoral-Popliteal By-Pass Graft 1 2 3 4 Thrombectomy 1 2 3 4 AV Shunt 1 2 3 4 Pacemaker Insertion 1 2 3 4 Scrub Laparascopic ProceduresCholecystectomy (Open) 1 2 3 4 Appendectomy 1 2 3 4 Hernia 1 2 3 4 Nissan 1 2 3 4 Colectomy 1 2 3 4 Gastrectomy 1 2 3 4 Inguinal/Ventral hernia Repair 1 2 3 4 Splenectomy 1 2 3 4 Bowel Rescetion/Colostomy 1 2 3 4 Thyroidectomy 1 2 3 4 Rectal Procedures 1 2 3 4 Esophagascopy/Gastrocopy 1 2 3 4 Scrub Pediatric CasesInguinal Hernia Repair 1 2 3 4 Pyloric Stenosis 1 2 3 4 Circumcision 1 2 3 4 Exploratory Laparotomy 1 2 3 4 Scrub Vascular SurgeryCarotid Endarterectomy 1 2 3 4 Abdominal Aoric Aneurysm 1 2 3 4 Femoral-Popliteal By-Pass Graft (Insitu) 1 2 3 4 Femoral-Popliteal By-Pass Graft (Graph) 1 2 3 4 Portacath, Tesio, Hickman 1 2 3 4 AV Shunt 1 2 3 4 Thrombecomy 1 2 3 4 Pacemaker Insertion 1 2 3 4 Arterial Stenting 1 2 3 4 Intra-Operative Angioplasty 1 2 3 4 Subclavian/Carotid By-Pass 1 2 3 4 Scrub OrthopedicsTotal Hip Replacement 1 2 3 4 Bipolar Hip 1 2 3 4 Compression Hip Screw 1 2 3 4 Total Knee Replacement 1 2 3 4 Knee Artoscopy 1 2 3 4 ACL Knee Repair 1 2 3 4 Harrington Rod or Similar 1 2 3 4 I.M. Rodding 1 2 3 4 Hand and Foot Procedures 1 2 3 4 Mini Fragment Screws & Plates 1 2 3 4 External Fixation 1 2 3 4 Shoulder Repair 1 2 3 4 Shoulder Arthoscopy 1 2 3 4 Spinal Fusion 1 2 3 4 Fracture Table Set-Up 1 2 3 4 Drills, Saws and Reamers 1 2 3 4 Scrub GynecologyD&C 1 2 3 4 Diagnostic Laparascope 1 2 3 4 Laparoscopic Asst'd Vaginal Hysterectomy 1 2 3 4 Abdominal Hysterectomy 1 2 3 4 Vaginal Hysterectomy 1 2 3 4 Anterior/Posterior Repair 1 2 3 4 MMK (Marshall Marchetti Krantz) 1 2 3 4 Tuboplasty 1 2 3 4 BLT (Bilateral Tubal Ligation) 1 2 3 4 C-Section 1 2 3 4 Scrub UrologyRadical Prostatectomy 1 2 3 4 Radical Lymph Node Dissection 1 2 3 4 Insertion Penile Prosthesis 1 2 3 4 Hydrocelectomy 1 2 3 4 Cystoscopy 1 2 3 4 Ureteroscopy 1 2 3 4 TURP/TURBT 1 2 3 4 Scrub NeurologyCervical Laminectomy (Anterior) 1 2 3 4 Cervical Laminectomy (Posterior) 1 2 3 4 Lumbar Lamincetomy, Discectomy 1 2 3 4 Percutaneous Micro Discectomy 1 2 3 4 Craniotomy for Tumor 1 2 3 4 Craniotomy for Aneurysm 1 2 3 4 Burr Holes 1 2 3 4 VP Shunts 1 2 3 4 Transphenoidal Hypothypectomy 1 2 3 4 Harrington Rod or Similar 1 2 3 4 Scrub PlasticsMammoplasty 1 2 3 4 Facelifts 1 2 3 4 Skin Grafts 1 2 3 4 Rhinoplasty 1 2 3 4 Cleft Lip Repair 1 2 3 4 Abdominalplasty 1 2 3 4 Blepharoplasty 1 2 3 4 Otoplasty 1 2 3 4 Muscle Flaps 1 2 3 4 Trauma 1 2 3 4 Transplant Surgery 1 2 3 4 Organ Procurements (Harvest) 1 2 3 4 Scrub ENTMiddle Ear 1 2 3 4 T&A 1 2 3 4 Myringotomy 1 2 3 4 Tympanoplasty 1 2 3 4 Radical Neck Dissection 1 2 3 4 Septoplasty 1 2 3 4 Sinus Endoscopy 1 2 3 4 Scrub ThoracicThoracotomy 1 2 3 4 Thoracoscopy 1 2 3 4 Age Specific CompetenciesInfant (Birth - 1 year) 1 2 3 4 Preschooler (ages 2-5 years) 1 2 3 4 Childhood (ages 6-12 years) 1 2 3 4 Adolescents (ages 13-21 years) 1 2 3 4 Young Adults (ages 22-39 years) 1 2 3 4 Adults (ages 40-64 years) 1 2 3 4 Older Adults (ages 65-79 years) 1 2 3 4 Elderly (ages 80+ years) 1 2 3 4 AuthorizationsSignature(Required)The information I have given is true and accurate to the best of my knowledge. I hereby authorize Hired by Matrix, Inc. to release this Emergency Room RN Skills Checklist to Client facilities of Hired by Matrix, Inc. in consideration of my assignment to work at those facilities.Your NameYour NameYour NameYour Name
