Or Nursing Orientation Checklist Template Details

The Operating Room Competency Checklist Form is a valuable tool for assessing the competency of medical professionals in the operating room. The form can be used to evaluate the capabilities of surgeons, anesthesiologists, and nurses. The checklist includes a variety of topics such as patient safety, team work, and surgical procedures. By using the form, hospitals can ensure that their staff is fully competent in all areas of the operating room.

Below is the information about the PDF you were in search of to fill out. It will show you just how long it will need to complete operating room competency checklist, what fields you will need to fill in and some further specific facts.

QuestionAnswer
Form NameOperating Room Competency Checklist
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesaorn operating room competency checklist, nurse competencies checklist operating room, orientation to the operating room, operating room nurse orientation checklist

Form Preview Example

Skills Self Assessment

OPERATING ROOM

Name: _________________________________

Date: ___________________

Please indicate your level of experience (1, 2, or 3.)

One year experience in profiled specialty required.

1. Limited - Less than one year 2. Experienced - One to Two years 3. Independent - Two or more years

Indicate Specialty:

RN

 

SCRUB TECH

 

 

 

 

 

 

 

 

 

 

 

Endoscopy

 

Circulate

 

Scrub

 

Colonoscopy / Sigmoidoscopy

1

2

3

1

 

2

 

3

Cystoscopy / Uteroscopy

 

 

 

 

 

 

 

 

Gastroscopy/ Esophagoscopy/ Bronchoscopy

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Laparoscopic Surgery

 

 

 

 

 

 

 

 

Specimen Management

 

 

 

 

 

 

 

 

Suctioning (Oral, nasal, trach)

 

 

 

 

 

 

 

 

Cardiac_Open Heart _Vascular

Circulate

 

Scrub

 

 

 

 

 

 

 

 

 

Abdominal Aortic Aneurysm

1

2

3

1

 

2

 

3

 

Aortic Resection

 

 

 

 

 

 

 

 

Aorto_Iliac Femoral Graft

 

 

 

 

 

 

 

 

 

AV Shunt

 

 

 

 

 

 

 

 

Endarterectomy Carotid/Femoral w/ graft

 

 

 

 

 

 

 

 

Femoral Popliteal Bypass Graft

 

 

 

 

 

 

 

 

Open Heart_Atrial/Ventricle Septal Defect

 

 

 

 

 

 

 

 

Open Heart_CoronaryArteryBypassGraft

 

 

 

 

 

 

 

 

Open Heart_PDA

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Open Heart_Tetrology of Fallot

 

 

 

 

 

 

 

 

Open Heart_Valve Replacement, Repair

 

 

 

 

 

 

 

 

Pacemaker Implantation or Repair

 

 

 

 

 

 

 

 

Pericardial Window

 

 

 

 

 

 

 

 

Ventricular Assist Devices

 

 

 

 

 

 

 

 

General (see Endoscopy)

Circulate

 

Scrub

 

Abdominal-perineal resection

1

2

3

1

 

2

 

3

Appendectomy / ruptured

 

 

 

 

 

 

 

 

 

Breast Biopsy

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Catheters_Hickman, Groshong, Portacath

 

 

 

 

 

 

 

 

Cholecystectomy / cholangiogram

 

 

 

 

 

 

 

 

Colon / Ileum resection

 

 

 

 

 

 

 

 

Colostomy / Ileostomy

 

 

 

 

 

 

 

 

Gastrectomy or Gastroplasty

 

 

 

 

 

 

 

 

Hemorrhoidectomy

 

 

 

 

 

 

 

 

Hepatic resection

 

 

 

 

 

 

 

 

 

Hernia repair

 

 

 

 

 

 

 

 

Laparotomy exploratory

 

 

 

 

 

 

 

 

Pediatric procedures

 

 

 

 

 

 

 

 

Pilonida cystectomy

 

 

 

 

 

 

 

 

 

Pyloric stenosis

 

 

 

 

 

 

 

 

Saphenous vein stripping

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Sentinel node biopsy

 

 

 

 

 

 

 

 

 

Splenectomy

 

 

 

 

 

 

 

 

Tenchkoff catheter

 

 

 

 

 

 

 

 

 

Thyroidectomy

 

 

 

 

 

 

 

 

 

Vagotomy

 

 

 

 

 

 

 

 

 

Whipple

 

 

 

 

 

 

 

 

Gynecology

 

Circulate

 

Scrub

 

 

AP Repair

1

2

3

1

 

2

 

3

Cesarean section / Tubal Ligation

 

 

 

 

 

 

 

 

Cystectomy (ovarian etc)

 

 

 

 

 

 

 

 

(D&C) Dilation & Curettage

 

 

 

 

 

 

 

 

Gynecology (cont.)

Circulate

 

Scrub

 

 

 

 

 

 

 

 

 

 

MMR (Marshall Marchetti Krantz)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Radiological insertion

 

 

 

 

 

 

 

 

TAH / BSO_Vaginal & Abdominal

 

 

 

 

 

 

 

 

Vaginal Reconstruction

 

 

 

 

 

 

 

 

Vaginectomy / Vulvectomy

 

 

 

 

 

 

 

 

Neurological

Circulate

 

Scrub

 

Burr Holes (Sub Dural Hematoma)

1

2

3

1

 

2

 

3

Crainotomy_Aneurysm

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Crainotomy_Decompression fracture

 

 

 

 

 

 

 

 

Crainotomy_Tumor

 

 

 

 

 

 

 

 

Instrumentation_Spinal fusion

 

 

 

 

 

 

 

 

Kyphoplasty Spinal

 

 

 

 

 

 

 

 

Laminectomy / Discectomy Anterior_Posterior

 

 

 

 

 

 

 

 

Pediatric procedures

 

 

 

 

 

 

 

 

Spinal Fusion_Anterior / Posterior

 

 

 

 

 

 

 

 

Steriotactics

 

 

 

 

 

 

 

 

Tongs_Crutchfied & Mayfield

 

 

 

 

 

 

 

 

VP/VA Shunt (Ventricular-Peritoneal)

 

 

 

 

 

 

 

 

Ophthalmology

Circulate

 

Scrub

 

Cataract extraction with IOL

1

2

3

1

 

2

 

3

Corneal Transplant

 

 

 

 

 

 

 

 

Enucleation

 

 

 

 

 

 

 

 

Iridectomy

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Phaco Emulsification

 

 

 

 

 

 

 

 

Sceral Buckle

 

 

 

 

 

 

 

 

Vitrectomy

 

 

 

 

 

 

 

 

Orthopedics

Circulate

 

Scrub

 

ACL (Anterior Cruciate Ligament)

1

2

3

1

 

2

 

3

Amputation limb

 

 

 

 

 

 

 

 

Arthroscopy (leg, shoulder, elbow)

 

 

 

 

 

 

 

 

Didget Reimplantation

 

 

 

 

 

 

 

 

External fixation application

 

 

 

 

 

 

 

 

Hand procedures

 

 

 

 

 

 

 

 

Hip Compression nails / pinning / screws

 

 

 

 

 

 

 

 

IM Rods (Intramedullary)

 

 

 

 

 

 

 

 

ORIF (Open Reduction Internal Fixation)

 

 

 

 

 

 

 

 

Pediatric procedures

 

 

 

 

 

 

 

 

Segmental Spinal Fixation

 

 

 

 

 

 

 

 

Tendon transplant

 

 

 

 

 

 

 

 

Total joint knee / hip / shoulder replacement

 

 

 

 

 

 

 

 

Oral_ENT

Circulate

 

Scrub

 

Adenoidectomy / Tonsillectomy

1

2

3

1

 

2

 

3

Caldwell-Luc

 

 

 

 

 

 

 

 

Cleft lip/palate repair

 

 

 

 

 

 

 

 

Dental procedures

 

 

 

 

 

 

 

 

Fracture Reduction facial / wiring

 

 

 

 

 

 

 

 

Frontal Flap Sinus procedure

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Radical neck dissection

 

 

 

 

 

 

 

 

Rhinopasty / Septoplasty / Tympanoplasty

 

 

 

 

 

 

 

 

TMJ exploration or arthroplasty

 

 

 

 

 

 

 

 

Tracheostomy

 

 

 

 

 

 

 

 

OR_HSGS

1

5_07_LKP

Skills Self Assessment

OPERATING ROOM

Plastics

Circulate

 

Scrub

 

Abdominoplasty

1

2

3

1

 

2

 

3

Blepharoplasty

 

 

 

 

 

 

 

 

Face Lift

 

 

 

 

 

 

 

 

Flaps_Free / Rotational

 

 

 

 

 

 

 

 

Liposuction

 

 

 

 

 

 

 

 

Mammoplasty_Augmentation

 

 

 

 

 

 

 

 

Mammoplasty_Reduction

 

 

 

 

 

 

 

 

Mammoplasty_TRAM flap / Reconstruction

 

 

 

 

 

 

 

 

Radical Mastectomy

 

 

 

 

 

 

 

 

Split Thickness Skin Graft

 

 

 

 

 

 

 

 

Thoracic

Circulate

 

Scrub

 

Chest Tube/Drains

1

2

3

1

 

2

 

3

Mediastinoscopy

 

 

 

 

 

 

 

 

Pneumonectomy_Lobectomy

 

 

 

 

 

 

 

 

Rib Resection

 

 

 

 

 

 

 

 

Thoracotomy

 

 

 

 

 

 

 

 

Thrombectomy_Embolectomy

 

 

 

 

 

 

 

 

VATS (Video Assisted Thoracoscopy)

 

 

 

 

 

 

 

 

Transplant_Procurment

Circulate

 

Scrub

 

Bone / Marrow

1

2

3

1

 

2

 

3

Corneal

 

 

 

 

 

 

 

 

Heart_Lung

 

 

 

 

 

 

 

 

Kidney

 

 

 

 

 

 

 

 

Liver

 

 

 

 

 

 

 

 

Pancreas

 

 

 

 

 

 

 

 

Trauma

Circulate

 

Scrub

 

Burns

1

2

3

1

 

2

 

3

Gunshot Stab Wounds_Abdomen

 

 

 

 

 

 

 

 

Gunshot Stab Wounds_Chest

 

 

 

 

 

 

 

 

Gunshot Stab Wounds_Head

 

 

 

 

 

 

 

 

MVA with Multiple injuries

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Traumatic Amputations

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Urological (see Endoscopy)

Circulate

 

Scrub

 

 

 

 

 

 

 

 

 

Bladder Suspension

1

2

3

1

 

2

 

3

 

 

 

 

 

 

 

 

 

Cysto Retrograde

 

 

 

 

 

 

 

 

Hypospadias repair

 

 

 

 

 

 

 

 

Implant_Prosthesis insertion/removal

 

 

 

 

 

 

 

 

Lithotripsy

 

 

 

 

 

 

 

 

Nephrectomy

 

 

 

 

 

 

 

 

Radical Node Dissection

 

 

 

 

 

 

 

 

Radical Prostatectomy

 

 

 

 

 

 

 

 

Radium Seed Implants

 

 

 

 

 

 

 

 

Stent placement

 

 

 

 

 

 

 

 

TURP

 

 

 

 

 

 

 

 

Vasectomy

 

 

 

 

 

 

 

 

I attest the information submitted is true and accurate to the best of my knowledge.

Name (print) ____________________________________________

EQUIPMENT (Use and Care of)

Circulate

 

Scrub

 

Argon Coagulator

1

2

3

1

 

2

 

3

Autoclave - Flash

 

 

 

 

 

 

 

 

Cell Saver

 

 

 

 

 

 

 

 

Cidex Soak

 

 

 

 

 

 

 

 

Cry-ophthalmic unit

 

 

 

 

 

 

 

 

CUSA

 

 

 

 

 

 

 

 

Dermatome (Brown, Zimmer, Padgett)

 

 

 

 

 

 

 

 

Drill assembly / usage (cordless & air/gas)

 

 

 

 

 

 

 

 

Drills_Codman Cranitome

 

 

 

 

 

 

 

 

Drills_Midas Rex

 

 

 

 

 

 

 

 

Drills_Neurotome

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Drills_Surgairtome

 

 

 

 

 

 

 

 

Electrical surgical unit & grounding pads

 

 

 

 

 

 

 

 

Endoscopic equipment (camera, video, etc)

 

 

 

 

 

 

 

 

Endoscopic Fiber optic luminator

 

 

 

 

 

 

 

 

Harmonic Scaple

 

 

 

 

 

 

 

 

Hypo/Hyperthermia Unit

 

 

 

 

 

 

 

 

Intestinal Stapling

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Microscope

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Nitrous Oxide

 

 

 

 

 

 

 

 

Pneumatic tourniquet

 

 

 

 

 

 

 

 

Robotics

 

 

 

 

 

 

 

 

Seris unit

 

 

 

 

 

 

 

 

Sterad machine

 

 

 

 

 

 

 

 

Table_OR, Fracture, Jackson

 

 

 

 

 

 

 

 

TPS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Ultrasonic cleaner

 

 

 

 

 

 

 

 

Vac Pack (Bean Bag)

 

 

 

 

 

 

 

 

Vacuum Curettage

 

 

 

 

 

 

 

 

Washer Sanitizer

 

 

 

 

 

 

 

 

Wilson Frame

 

 

 

 

 

 

 

 

OTHER

Circulate

 

Scrub

 

 

 

 

 

 

 

 

 

Blood / Blood Products Administration

1

2

3

1

 

2

 

3

 

 

 

 

 

 

 

 

 

Catheter Care/Insertion

 

 

 

 

 

 

 

 

Conscious Sedation

 

 

 

 

 

 

 

 

Diseases Infectious/Communicable

 

 

 

 

 

 

 

 

Hemodynamic Monitoring

 

 

 

 

 

 

 

 

IV Care/Therapy

 

 

 

 

 

 

 

 

Lab Obtain / Interpret

 

 

 

 

 

 

 

 

Latex Allergy Guidelines/Procedure

 

 

 

 

 

 

 

 

O2 Saturations / Oxygen Therapy

 

 

 

 

 

 

 

 

Pain Assess / Manage

 

 

 

 

 

 

 

 

Restraints

 

 

 

 

 

 

 

 

System Assessment

 

 

 

 

 

 

 

 

Teaching Pt/Others

 

 

 

 

 

 

 

 

Wound / Dressing Care

 

 

 

 

 

 

 

 

CERTIFICATIONS

Expires RN

Expires ST

Certified Scrub Tech

 

 

 

 

 

 

 

 

CNOR Certification

 

 

 

 

 

 

 

 

Laser Certification

 

 

 

 

 

 

 

 

Signature:______________________________

Date: ________________________________

OR_HSGS

2

5_07_LKP