Certified Surgical First Assistant Skills Checklist Personal InformationName(Required) First Middle Last Date MM slash DD slash YYYY Key To Competency Levels0 – No Experience 1 – Minimal experience, need review and supervision, have performed at least once 2 – Comfortable performing with resource available 3 – Competent to perform independently and safely 4 – Expert, able to act as resource to othersMiscellaneousAdult Respiratory/ Cardiac Arrest 0 1 2 3 4 Autoclave 0 1 2 3 4 Automated Med Dispensing Systems 0 1 2 3 4 Care of Scopes & Fiberoptic Equipment 0 1 2 3 4 Cidex Soap 0 1 2 3 4 Crash Cart 0 1 2 3 4 Defibrillator 0 1 2 3 4 Electronic Documentation 0 1 2 3 4 Hand-off Communication 0 1 2 3 4 Isolation Precautions 0 1 2 3 4 Patient Identification 0 1 2 3 4 Pediatric Respiratory/ Cardiac Arrest 0 1 2 3 4 Standard Precautions 0 1 2 3 4 Universal Protocol 0 1 2 3 4 Experience With AgesNewborn/Neonate (birth to 30 days) 0 1 2 3 4 Infant (1 month to 1 year) 0 1 2 3 4 Toddler (1 year to 3 years) 0 1 2 3 4 Preschooler (3 years to 5 years) 0 1 2 3 4 School Age Child (5 years to 12 years) 0 1 2 3 4 Adolescents (12 years to 18 years) 0 1 2 3 4 Young Adults (18 years to 39 years) 0 1 2 3 4 Middle Adults (39 years to 64 years) 0 1 2 3 4 Older Adults (64 years to 79 years) 0 1 2 3 4 Elderly Adults (over 79+ years) 0 1 2 3 4 General SurgeryAbdominal Perineal Resection 0 1 2 3 4 Adrenalectomy 0 1 2 3 4 Bowel Resection 0 1 2 3 4 Cholecystectomy 0 1 2 3 4 Colostomy/Ileostomy 0 1 2 3 4 Gastrectomy 0 1 2 3 4 Hemicolectomy 0 1 2 3 4 Hepatic Resection 0 1 2 3 4 Herniorrhaphy-Femoral/ Inguinal 0 1 2 3 4 Hiatal Herniorrhaphy- Transabdominal 0 1 2 3 4 Pancreatectomy 0 1 2 3 4 Organ Procurement 0 1 2 3 4 Radical Mastectomy 0 1 2 3 4 Saphenous Vein Ligation and Stripping 0 1 2 3 4 Splenectomy 0 1 2 3 4 Thyroidectomy 0 1 2 3 4 Tracheostomy 0 1 2 3 4 Whipple Procedure 0 1 2 3 4 Laparoscopic ProceduresHysterectomy 0 1 2 3 4 Cholecystectomy 0 1 2 3 4 Appendectomy 0 1 2 3 4 Hernia Repair 0 1 2 3 4 Colon Resection 0 1 2 3 4 GynecologyCaesarean Section 0 1 2 3 4 Dilation & Curettage 0 1 2 3 4 Hysterectomy-Vaginal 0 1 2 3 4 Hysterectomy-Abdominal 0 1 2 3 4 Laser Surgery 0 1 2 3 4 Radium Insertion 0 1 2 3 4 Salpingo- Oopherectomy 0 1 2 3 4 Shirodkar Procedure 0 1 2 3 4 Termination of Pregnancy 0 1 2 3 4 Tubal Ligation 0 1 2 3 4 Vaginectomy 0 1 2 3 4 Vaginal Reconstruction 0 1 2 3 4 G.U. and CystoCircumcision 0 1 2 3 4 Cystoscopy/ Cystostomy 0 1 2 3 4 Cystectomy 0 1 2 3 4 Hypospadius Repair 0 1 2 3 4 Ileal Loop 0 1 2 3 4 Lithotripsy 0 1 2 3 4 Nephrectomy 0 1 2 3 4 Orchiectomy 0 1 2 3 4 Penile Implant 0 1 2 3 4 Prostatectomy 0 1 2 3 4 Ureterolithotomy 0 1 2 3 4 Ureteroscopy 0 1 2 3 4 T.U.R.P./T.U.R.B 0 1 2 3 4 Vasectomy 0 1 2 3 4 OrthopedicAmputation- Leg/ Arm 0 1 2 3 4 Application of Halo Traction 0 1 2 3 4 Arthroscopy/ Arthrotomy 0 1 2 3 4 Closed Pinning & Reduction of Extremities 0 1 2 3 4 External Compression Devices 0 1 2 3 4 Insertion of Finger Prosthesis 0 1 2 3 4 Total Joint Replacement- Knee, Hip, Shoulder 0 1 2 3 4 Spinal Fusion-Harrington Rods 0 1 2 3 4 Spica Cast Application 0 1 2 3 4 O.R.I.F.-Shoulder, Hip, Humerus, etc. 0 1 2 3 4 Repair of Dislocation 0 1 2 3 4 Patellectomy 0 1 2 3 4 Tendon Implants & Reanastomosis 0 1 2 3 4 NeurosurgeryAnterior Cervical Fusion 0 1 2 3 4 AV Malformation 0 1 2 3 4 Burrholes for Subdural Hematoma 0 1 2 3 4 Craniotomy 0 1 2 3 4 Discectomy/ Laminectomy 0 1 2 3 4 Laminectomy 0 1 2 3 4 Meningocele Repair 0 1 2 3 4 Nerve Stimulators 0 1 2 3 4 Shunt Procedures- VP/ VA 0 1 2 3 4 Spinal Procedures/ Fusions 0 1 2 3 4 PlasticsAbdominoplasty/Abdominal Lipectomy 0 1 2 3 4 Augmentation Mammoplasty 0 1 2 3 4 Breast Reduction/ Reconstruction 0 1 2 3 4 Cleft Lip/Palate Repair 0 1 2 3 4 Dermabrasion 0 1 2 3 4 Digital Flexor Tendon Repair 0 1 2 3 4 Face Lift 0 1 2 3 4 Liposuction 0 1 2 3 4 Otoplasty 0 1 2 3 4 Rhinoplasty 0 1 2 3 4 Reduction of Facial Fracture 0 1 2 3 4 Scar Revisions 0 1 2 3 4 Skin Grafting 0 1 2 3 4 EyeExcision of Chalazion 0 1 2 3 4 Canthotomy 0 1 2 3 4 Correction of Ectropian/ Entropian 0 1 2 3 4 Corneal Transplant 0 1 2 3 4 Enucleation 0 1 2 3 4 I.O.I. Implants 0 1 2 3 4 Lacrimal Duct Probing 0 1 2 3 4 Refractive Keratoplasty 0 1 2 3 4 Repair of Retinal Detachment 0 1 2 3 4 Vitrectomy 0 1 2 3 4 Ear, Nose & ThroatCaldwell-Luc 0 1 2 3 4 Ethmoidectomy 0 1 2 3 4 Frontal Flap Sinus Procedure 0 1 2 3 4 Laryngectomy 0 1 2 3 4 Radical Neck 0 1 2 3 4 Septoplasty 0 1 2 3 4 Sinusotomy 0 1 2 3 4 Tonsillectomy & Adenoidectomy 0 1 2 3 4 Tracheostomy 0 1 2 3 4 Myringotomy 0 1 2 3 4 Mastoidectomy 0 1 2 3 4 Tympanoplasty 0 1 2 3 4 Stapedectomy 0 1 2 3 4 Nasal Polypectomy 0 1 2 3 4 Laryngoscopy 0 1 2 3 4 EndoscopyBronchoscopy 0 1 2 3 4 CardiothoracicChest Tube Set- Up 0 1 2 3 4 Pneumonectomy/ Lobectomy 0 1 2 3 4 Septal Defect Repair 0 1 2 3 4 Sternal Splitting 0 1 2 3 4 Thoracotomy 0 1 2 3 4 Bronchoscopy 0 1 2 3 4 Lung/ Wedge Resection 0 1 2 3 4 Vein Harvesting 0 1 2 3 4 A-V Shunts 0 1 2 3 4 Aortic Aneurysm, Abdominal 0 1 2 3 4 Aortofemoral Bypass 0 1 2 3 4 Graft Insertion 0 1 2 3 4 Cardiac Valve Replacement 0 1 2 3 4 Coronary Artery Bypass Graft- on Pump 0 1 2 3 4 Endarterectomy- Carotid/ Femoral 0 1 2 3 4 Femoral- Popliteal Bypass 0 1 2 3 4 External Temporary Pacemaker 0 1 2 3 4 Internal Pacemaker Insertion 0 1 2 3 4 Intra-Aortic Balloon Pump Catheter 0 1 2 3 4 Patent Ductus Repair 0 1 2 3 4 Pericardial Windows 0 1 2 3 4 Portasystemic Shunt 0 1 2 3 4 Repair of Septal Defects 0 1 2 3 4 Thrombectomy 0 1 2 3 4 Vena Cava Ligation 0 1 2 3 4 TransplantsBone Marrow 0 1 2 3 4 Pancreas 0 1 2 3 4 Heart 0 1 2 3 4 Lung 0 1 2 3 4 Liver 0 1 2 3 4 Multhorgan 0 1 2 3 4 Kidney 0 1 2 3 4 Eye 0 1 2 3 4 TraumaBurns 0 1 2 3 4 MVA 0 1 2 3 4 Gun Shot Wounds 0 1 2 3 4 Stab Wounds 0 1 2 3 4 EquipmentRobotics 0 1 2 3 4 Fracture Tables 0 1 2 3 4 Video Systems 0 1 2 3 4 CUSA 0 1 2 3 4 Cell Saver 0 1 2 3 4 PACS Diagnostics 0 1 2 3 4 Electrocautery 0 1 2 3 4 Drills 0 1 2 3 4 Saws 0 1 2 3 4 Stapling Devices 0 1 2 3 4 Cardiac Monitors 0 1 2 3 4 Position Patient Per Surgeon's Order 0 1 2 3 4 Pressure Point Paddling 0 1 2 3 4 Apply Tourniquet as Ordered 0 1 2 3 4 Protect From Nerve Damage 0 1 2 3 4 Thermoregulation 0 1 2 3 4 Use of Fracture Table 0 1 2 3 4 Use of Head Stabilizer 0 1 2 3 4 Use of Body Stabilizer 0 1 2 3 4 Use of C-arm Extensions 0 1 2 3 4 Skin Assessment 0 1 2 3 4 Use of Retractors 0 1 2 3 4 Packing with Sponges 0 1 2 3 4 Digital Manipulation of Tissue 0 1 2 3 4 Suctioning, Irrigation, Sponging 0 1 2 3 4 Manipulation of Surgical Materials (Loops, Tags) 0 1 2 3 4 Clamping/Cauterizing Vessels or Tissues 0 1 2 3 4 Tying/Ligating Clamped Vessels or Tissues 0 1 2 3 4 Apply Hemostatic Clips 0 1 2 3 4 Place Local Hemostatic Agents 0 1 2 3 4 Direct Digital Pressure 0 1 2 3 4 Assist in Volume Replacement 0 1 2 3 4 Assist in Autotransfusion 0 1 2 3 4 Suturing: All Wound Layers Including Muscle & Fascia 0 1 2 3 4 Wound dressing: Liquid or Spray Occlusive 0 1 2 3 4 Absorbent Immobilizing Dressing 0 1 2 3 4 Assist to Secure Drainage System to Tissue 0 1 2 3 4 Insert/Remove Foley 0 1 2 3 4 Drape Patient 0 1 2 3 4 Electrocautery Mono 0 1 2 3 4 Electrocautery Bipolar 0 1 2 3 4 Cut Tissue 0 1 2 3 4 Harvest Saphenous Vein, Including Skin Incision 0 1 2 3 4 Dissect Common Femoral Artery and Bifurcate 0 1 2 3 4 Insert Drainage Tubes 0 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 Certified Surgical First Assistant Skills Checklist to Client facilities of Hired by Matrix, Inc. in consideration of my assignment to work at those facilities.
