CVOR RN
Name
Email
LAST 4 OF SSN
This checklist was electronically signed on (Today’s date)
Instructions: This checklist is meant to serve as a general guideline for our client facilities as to the level of your skills within your nursing specialty. Please use the scale below to describe your experience/expertise in each area listed below.
Proficiency Scale:
1 ★ = No Experience
2 ★★ = Very Little Experience
3 ★★★ = Experience
4 ★★★★ = Very Experienced
Skill
Circulating
Scrub
da Vinci Procedures
Coronary Artery By-Pass
Mitral Valve Repair/ Replacement
Aortic Valve Replacement
Multiple Valve Transposition
Septal Defects
Ventricular Aneurysm Repair
Bring Back Heart
Pericardial Window
Intra-Aortic Balloon Insertion
Heartport or Similar CABG
Thoraco approach Mid-Cab
Aortic Arch Replacement
Aortic Valve Conduit
Mechanical Heart/ LVAD
Pediatric Hearts
Tetrology of Fallot
Chamberlain Procedure
Femoral Artery Cannulation
AICD Insertion
Saphenous Vein Harvest
Endoscopic Vein Harvest
Gastric Artery Harvest
Radial Vein Harvest
Carotid Endarterectomy
Abdominal Aortic Aneurysm
Femoral-Popliteal By-Pass Graft
Thrombectomy
AV Shunt
Pacemaker Insertion
AKA/ BKA (Amputation)
Radical Mastectomy
Abdominal- Perineal Resection
Cholecystectomy (Open)
Exploratory Laparotomy
Appendectomy
Cholecystectomy
Hernia
Nissan
Colectomy
Gastrectomy
Inguinal/ Ventral Hernia Repair
Splenectomy
Bowel Resection/ Colostomy
Thyroidectomy
Rectal Procedures
Esophagascopy/ Gastroscopy
Inguinal Hernia Repair
Pyloric Stenosis
Circumcision
Femoral-Popliteal By-Pass Graft (Insitu)
Femoral-Popliteal By-Pass Graft (Graph)
Portacath, Tesio, Hickman
Arterial Stenting
Intra- Operative Angioplasty
Subclavin/ Carotid By-Pass
Total Hip Replacement
Bipolar Hip
Compression Hip Screw
Total Knee Replacement
Knee Artoscopy
ACL Knee Repair
Harrington Rod or Similar
I.M. Rodding
Hand and Foot Procedures
Mini Fragment Screws & Plates
Standard Fragment Screws & Plates
Large Fragment Screws & Plates
External Fixation
Shoulder Repair
Shoulder Arthoscopy
Spinal Fusion
Fracture Table Set-Up
Drills, Saws and Reamers
D & C
Diagnostic Laparascope
Laparoscopic Assisted Vaginal Hysterectomy
Abdominal Hysterectomy
Vaginal Hysterectomy
Anterior/ Posterior Repair
MMK (Marshall Marchetti Krantz)
Tuboplasty
BLT (Bilateral Tubal Ligation)
C- Section
Radical Prostatectomy
Radical Lymph Node Dissection
Insertion Penile Prosthesis
Hydrocelectomy
Cystoscopy
Ureteroscopy
TURP/ TURBT
Ultrasonic Lithotripsy
Cervical Laminectomy (Anterior)
Cervical Laminectomy (Posterior)
Lumbar Laminectomy, Discectomy
Percutaneous Micro Discectomy
Craniotomy for Tumor
Craniotomy for Aneurysm
Burr Holes
VP Shunts
Transphenoidal Hypothypectomy
Mammoplasty
Facelifts
Skin Grafts
Rhinoplasty
Cleft Lip Repair
Abdominalplasty
Blepharoplasty
Otoplasty
Muscle Flaps
Trauma
Transplant Surgery
Organ Procurements (Harvest)
Middle Ear
T & A
Myringotomy
Tympanoplasty
Radical Neck Dissection
Septoplasty
Sinus Endoscopy
Thoracotomy
Thoracoscopy
Insertion Chest Tubes
Esophageal Repair
Pneumonectomy/ Lobectomy
I hereby certify that ALL information I have provided on this skills checklist and all other documentation is true and accurate. I understand and acknowledge that any misrepresentation or omission may result in disqualification from employment and/or immediate termination.
