| Name |
|
| Date |
|
Please indicate your level of experience in each of the following.
|
| |
| GENERAL SKILLS |
| Advanced directives |
|
| Cardiac arrest/adult CPR |
|
| Cardiac arrest/infant-child CPR |
|
| End of life care |
|
| Emergency Codes |
|
| Disaster protocols |
|
| Universal protocols |
|
| Infection control |
|
| Blood Glucose Monitoring (BGM) |
|
| Patient/family teaching |
|
| Restraints |
|
| Diabetes mellitus – management in OR |
|
| Isolation |
|
| Pressure ulcers – prevention |
|
| Life/transfer devices |
|
| Specialty beds |
|
| Minimize risk for falls |
|
| |
| 2024 NATIONAL PATIENT SAFETY GOALS |
NPSG.01.01.01
• Identify patients correctly |
|
| • Use patients name and date of birth |
|
| • Make sure correct patient gets the correct medicine and treatment |
|
Improve staff communication
|
|
NPSG.02.03.01
Get important test results to the right staff person on time. |
|
Use medicines safely
|
|
NPSG.03.04.01
Before a proceedure, label medicines that are not labeled. For example, medicines in syringes, cups and basins. Do this in the area where medicines and supplies are set up. |
|
NPSG.03.05.01
Take extra care with patients who take medicines to thin their blood. |
|
NPSG.03.06.01
Record and pass along correct information about a patient’s medicines. Find out what medicines the patient is taking. Compare those medicines to new medicines given to the patient. Give the patient written information about the medicines they need to take. Tell the patient it is important to bring their up-to-date list of medicines every time they visit their doctor. |
|
| Use Alarms Safely |
|
NPSG.06.01.01
Make improvements to ensure that alarms on medical equipment are heard and responded to on time. |
|
| Prevent infection |
|
NPSG.07.01.01
Use the hand cleaning guidelines from the Centers of Disease Control and Prevention or the World Health Organization. Set goals for improving hand cleaning |
|
| Identify patient safety risks |
|
NPSG.15.01.01
Reduce the risk for suicide. |
|
| Improve health care equity |
|
NPSG.16.01.01
Improving health care equity is a quality and patient safety priority. For example, health care disparities in the patient population are identified and a written plan describes ways to improve health care equity. |
|
| Prevent mistakes in surgery |
|
UP.01.01.01
Make sure that the correct surgery is done on the correct patient and at the correct place on the patient’s body. |
|
UP.01.02.01
Mark the correct place on the patients body where the surgery is to be done. |
|
UP.01.03.01
Pause before the surgery to make sure that a mistake is not being made. |
|
| |
| COMPUTERIZED CHARTING |
| Health Connect |
|
| Meditech |
|
| Cerner |
|
| McKesson |
|
| EPIC |
|
| Camis |
|
| Affinity |
|
| Wellsoft — ER |
|
| T–System — ER |
|
| Automated medication dispensing |
|
| Bar coding for medication administration |
|
| |
| ADMITTING/FACT GATHERING ACTIVITY |
| Verbal patient interview |
|
| Chart review |
|
| Assess vital signs |
|
| Physical systems assessment |
|
| Patient/family education |
|
| Social/spiritual support |
|
| |
| PRE-OP ASSESSMENT/ACTIVITIES |
| Verify Patient I.D. and surgical procedure |
|
| Verify required consents for surgery, blood transfusions, anesthesia, photographs,specimen disposal and Advanced Directives |
|
| Identify abnormal lab values: Hg, Hct Lytes, CPK, LDH, SGOT, PT, PTT, bleed, Time, Platelets, Glucose, HCG |
|
| Assess risk of malignant hyperthermia |
|
| Coordinate/communicate findings with anesthesia, surgeon, and scrub as necessary and implement corrective measures as ordered |
|
| Identify sensory/mobility impairments |
|
| Determine compensatory positioning needs |
|
| Verify adequacy of room preparations supplies, instruments, equipment and drugs |
|
| Perform Pre-op counts per policy |
|
| Obtain back-up or additional equipment and supplies to prepare for untoward eventualities based upon above Pre-op findings |
|
| |
| INTRA-OP ACTIVITIES |
| Maintain patient privacy |
|
| Use universal precautions |
|
| Safety in transfer to OR table |
|
| Assist with induction and intubation: Observe for potential cardiac dysrhythmias, laryngospasm, low O2 Sat., CO2 return, apply cricold pressure as directed, suctionprn, assess chest expansion and breath sounds. Administer emergency drugs as directed. |
|
| Position and pad bony areas in accordance with needed surgical exposure |
|
| Prep per policy |
|
| Observe for breaks in sterile technique and make corrections |
|
| Anticipate needs for surgical team |
|
| Monitor blood loss and report it |
|
| Communicate progress with family or nursing unit |
|
| Maintain operative record per policy |
|
| Perform closing counts per policy |
|
| Assist anesthesia with reversal and extubation |
|
| |
| GENERAL |
Scrub
Circulate |
Abdominal perineal resection |
|
Scrub
Circulate |
Acute Abdomen |
|
Scrub
Circulate |
Adrenalectomy |
|
Scrub
Circulate |
Appendectomy |
|
Scrub
Circulate |
Breast Biopsy |
|
Scrub
Circulate |
Colectomy |
|
Scrub
Circulate |
Colostomy/iliostomy |
|
Scrub
Circulate |
Chemotherapy/catheter insertion |
|
Scrub
Circulate |
Cholangiograms/cholecystectomy |
|
Scrub
Circulate |
Cholecystectomy by laparoscopy |
|
Scrub
Circulate |
Colon resection |
|
Scrub
Circulate |
Gastrectomy/gastrostomy |
|
Scrub
Circulate |
Hemicolectomy |
|
Scrub
Circulate |
Hemorrhoidectomy |
|
Scrub
Circulate |
Hepatic resection |
|
Scrub
Circulate |
Herniorrhaphy/femoral/inguinal
umbilical |
|
Scrub
Circulate |
Hiatal Herniorrhpy |
|
Scrub
Circulate |
Jejunostomy |
|
Scrub
Circulate |
Laparascopy |
|
Scrub
Circulate |
LaVeen shunting |
|
Scrub
Circulate |
Liver resection/harvest/transplant |
|
Scrub
Circulate |
Hickman/groshong portacath insertion |
|
Scrub
Circulate |
Mastectomy |
|
Scrub
Circulate |
Organ procurement |
|
Scrub
Circulate |
Omphalecele repair |
|
Scrub
Circulate |
Pancreatectomy/pracreatogram |
|
Scrub
Circulate |
Peritoneal dialysis catheter |
|
Scrub
Circulate |
Thyroidectomy |
|
Scrub
Circulate |
Splenectomy |
|
Scrub
Circulate |
Vagotomy |
|
Scrub
Circulate |
Vein ligation & stripping |
|
| |
| GYNECOLOGY |
Scrub
Circulate |
Cesarean section |
|
Scrub
Circulate |
Colpotomy |
|
Scrub
Circulate |
Dilation /curettage (D & C) |
|
Scrub
Circulate |
Hysterectomy, abdominal |
|
Scrub
Circulate |
Hysterectomy, vaginal |
|
Scrub
Circulate |
Marshall – Marchetti |
|
Scrub
Circulate |
Marsupialization, Bartholin cyst |
|
Scrub
Circulate |
Ovarian cystectomy |
|
Scrub
Circulate |
Radium insertion |
|
Scrub
Circulate |
Sacral spinus fixation |
|
Scrub
Circulate |
Shirodkar procedure |
|
Scrub
Circulate |
Suction curettage |
|
Scrub
Circulate |
Vaginal reconstruction |
|
Scrub
Circulate |
Vaginectomy/vulvectomy |
|
| |
| EAR, NOSE & THROAT |
Scrub
Circulate |
Adenoidectomy |
|
Scrub
Circulate |
Caldwell – Luc |
|
Scrub
Circulate |
Cleft lip/palate repair |
|
Scrub
Circulate |
Closed reduction nasal fracture |
|
Scrub
Circulate |
Ethmoidectomy |
|
Scrub
Circulate |
Excision of salivary gland tumor |
|
Scrub
Circulate |
Fenestration procedure |
|
Scrub
Circulate |
Frontal flap sinus procedure |
|
Scrub
Circulate |
Glossectomy |
|
Scrub
Circulate |
Laryngectomy |
|
Scrub
Circulate |
Mandibulectomy |
|
Scrub
Circulate |
Mastoidectomy |
|
Scrub
Circulate |
Maxillary advancement with hip graft |
|
Scrub
Circulate |
Maxillectomy |
|
Scrub
Circulate |
Myringoplasty |
|
Scrub
Circulate |
Myringotomy/with PE tube insertion |
|
Scrub
Circulate |
Nasal polypectomy |
|
Scrub
Circulate |
Open reduction facial fracture |
|
Scrub
Circulate |
Open reduction nasal fracture |
|
Scrub
Circulate |
Parotidectomy |
|
Scrub
Circulate |
Pharyngeal flap procedure |
|
Scrub
Circulate |
Radial neck dissection |
|
| |
| ORAL |
Scrub
Circulate |
Closed reduction facial fractures/wiring |
|
Scrub
Circulate |
Excision odontoma |
|
Scrub
Circulate |
Extraction of deciduous teeth |
|
Scrub
Circulate |
Extraction of impacted molars |
|
Scrub
Circulate |
Fractured jaws, mandibular and zagomatic |
|
Scrub
Circulate |
LeFort osteotomies |
|
Scrub
Circulate |
Maxillary procedure with graft |
|
Scrub
Circulate |
Pediatric dentistry |
|
Scrub
Circulate |
Sagittal osteotomy |
|
Scrub
Circulate |
Temporomandibular joint (TMJ) with arthroplasty |
|
Scrub
Circulate |
TMJ exploration |
|
Scrub
Circulate |
Radical neck dissection |
|
Scrub
Circulate |
Septoplasty |
|
Scrub
Circulate |
T & A with laser |
|
| |
UROLOGY |
Scrub
Circulate |
Circumcision |
|
Scrub
Circulate |
Cystectomy |
|
Scrub
Circulate |
Cystoscopy/ureteroscopy |
|
Scrub
Circulate |
Hypospadias repair |
|
Scrub
Circulate |
Kidney harvest/transplant |
|
Scrub
Circulate |
Lithotomy – open |
|
Scrub
Circulate |
Nephrectomy |
|
Scrub
Circulate |
Nephrolithotomy orchiopexy |
|
Scrub
Circulate |
Testicular/penile |
|
Scrub
Circulate |
Prostatectomy-perineal subra-pubic |
|
Scrub
Circulate |
Ryeloplasty |
|
Scrub
Circulate |
Radical node dissection |
|
Scrub
Circulate |
Scott incontinence device |
|
Scrub
Circulate |
Turp |
|
Scrub
Circulate |
Ureterolithotomy |
|
Scrub
Circulate |
Vasectomy |
|
Scrub
Circulate |
Vasovasotomy |
|
Scrub
Circulate |
Waterhouse procedure |
|
Scrub
Circulate |
Venodyne robotics (DaVinci) |
|
| |
| HEET |
Scrub
Circulate |
Rhinoplasty/deptoplasty |
|
Scrub
Circulate |
T & A |
|
Scrub
Circulate |
Radial neck |
|
Scrub
Circulate |
Bronchoscopy-Rigid |
|
Scrub
Circulate |
Bronchoscopy-fiberoptic with image |
|
Scrub
Circulate |
Choclear implant |
|
Scrub
Circulate |
Esophagoscopy-rigid |
|
Scrub
Circulate |
Laryngectomy |
|
Scrub
Circulate |
Laryngoscopy-micro |
|
Scrub
Circulate |
Maxillary/Mandibular fractures |
|
Scrub
Circulate |
Myringotomy |
|
Scrub
Circulate |
Orbital fracture |
|
| |
| EQUIPMENT |
Scrub
Circulate |
Argon beam coagulator |
|
Scrub
Circulate |
Camera/video systems |
|
Scrub
Circulate |
Cell saver |
|
Scrub
Circulate |
Cidex soak |
|
Scrub
Circulate |
Cryo-ophthalmic unit |
|
Scrub
Circulate |
Cavitron Ultrasonic Surgical Aspirator (CUSA) |
|
Scrub
Circulate |
Hypo/hyperthermia unit |
|
Scrub
Circulate |
Drills and saws |
|
Scrub
Circulate |
Electrosurgical unit |
|
Scrub
Circulate |
Fiber optic luminator |
|
Scrub
Circulate |
Cavitron |
|
Scrub
Circulate |
Autoclave |
|
Scrub
Circulate |
Fracture tables |
|
Scrub
Circulate |
Harmonic scalpel |
|
Scrub
Circulate |
Ligasure |
|
Scrub
Circulate |
Stapling devices |
|
Scrub
Circulate |
Mesh graft/dermatone |
|
Scrub
Circulate |
Microscopes |
|
Scrub
Circulate |
Nitrogen tank |
|
Scrub
Circulate |
Pneumatic tourniquet |
|
Scrub
Circulate |
Stealth |
|
Scrub
Circulate |
Steris unit |
|
Scrub
Circulate |
Pulsevac irrigation |
|
Scrub
Circulate |
Autotransfusion system |
|
Scrub
Circulate |
Laser equipment |
|
Scrub
Circulate |
Care of scopes & fiberoptic equipment |
|
Scrub
Circulate |
Dermatone |
|
Scrub
Circulate |
Brown |
|
Scrub
Circulate |
Padgett |
|
Scrub
Circulate |
Zimmer |
|
Scrub
Circulate |
Disposable grounding pads |
|
Scrub
Circulate |
Drills |
|
Scrub
Circulate |
3-M maxi driver |
|
Scrub
Circulate |
Codman craniotome |
|
Scrub
Circulate |
Hall air driver |
|
Scrub
Circulate |
Hall dental |
|
Scrub
Circulate |
Hall neuotome |
|
Scrub
Circulate |
Midax Rex/Anspach |
|
Scrub
Circulate |
Minidrive |
|
| |
OPHTHALMOLOGY |
Scrub
Circulate |
Corneal transplant |
|
Scrub
Circulate |
Cataract extraction with IOL |
|
Scrub
Circulate |
Dacryocystectomy |
|
Scrub
Circulate |
Lid and muscle procedures |
|
Scrub
Circulate |
Orbital implant |
|
Scrub
Circulate |
Iridectomy |
|
Scrub
Circulate |
Pterygium repair |
|
Scrub
Circulate |
Phaco emulsification |
|
Scrub
Circulate |
Repair orbital blowout fracture |
|
Scrub
Circulate |
Recession resection |
|
Scrub
Circulate |
Vitrectomy |
|
Scrub
Circulate |
Scleral buckle |
|
Scrub
Circulate |
Enucleation |
|
| |
| OPEN HEART/THORACIC |
Scrub
Circulate |
Cervical rib excision |
|
Scrub
Circulate |
Closed thoracotomy |
|
Scrub
Circulate |
Acending aortic aneurysm |
|
Scrub
Circulate |
CABG |
|
Scrub
Circulate |
Commissurotomy (mitral) |
|
Scrub
Circulate |
Decending arotic aneurysm |
|
Scrub
Circulate |
Esophagectomy |
|
Scrub
Circulate |
Heller procedure |
|
Scrub
Circulate |
Open heart procedures |
|
Scrub
Circulate |
Mitral or aortic valve replacement |
|
Scrub
Circulate |
Patent ductus arteriosus |
|
Scrub
Circulate |
Septal defect repairs |
|
Scrub
Circulate |
Tetrology of Fallot |
|
Scrub
Circulate |
LVAD implantation |
|
Scrub
Circulate |
Mediastinoscopy |
|
Scrub
Circulate |
Pacemaker implantation-endocardial |
|
Scrub
Circulate |
Pacemaker implantation-myocardial |
|
Scrub
Circulate |
Pericardiectomy |
|
Scrub
Circulate |
Resection coarctation aorta |
|
Scrub
Circulate |
Rib resection |
|
Scrub
Circulate |
Thoracoplasty |
|
Scrub
Circulate |
Tracheal resection |
|
Scrub
Circulate |
Transthoracic diaphragmatic herniorrhaphy |
|
| |
| VASCULAR |
Scrub
Circulate |
A-V access graft |
|
Scrub
Circulate |
Aortic aneurysm with graft replacement |
|
Scrub
Circulate |
Endarterectomy/carotid-femoral |
|
Scrub
Circulate |
Peripheral vascular bypass procedures |
|
Scrub
Circulate |
Resection carotid aneurysm with graft |
|
Scrub
Circulate |
Thrombectomy/embolectomy |
|
| |
| NEUROLOGY |
Scrub
Circulate |
A-V malformation |
|
Scrub
Circulate |
Anterior cervical spine |
|
Scrub
Circulate |
Anterior laparoscopic spine procedures |
|
Scrub
Circulate |
Anterior lumbar interbody fusion (ALIF) |
|
Scrub
Circulate |
Burr holes for subdural hematoma |
|
Scrub
Circulate |
Carotid ligation |
|
Scrub
Circulate |
Cervical sympathectomy |
|
Scrub
Circulate |
Craniectomy for decompression fracture |
|
Scrub
Circulate |
Cranioplasty/craniotomy |
|
Scrub
Circulate |
Clipping of aneurysm |
|
Scrub
Circulate |
Tumor excision |
|
Scrub
Circulate |
Using stealth equipment (stealth craniotomy) |
|
Scrub
Circulate |
Discectomy |
|
Scrub
Circulate |
Hypophysectomy |
|
Scrub
Circulate |
Insertion nerve stimulators/medication pumps |
|
Scrub
Circulate |
Laminectomy |
|
Scrub
Circulate |
Myelomeningocele repair |
|
Scrub
Circulate |
Pedicle screw insertion |
|
Scrub
Circulate |
Posterior lumbar interbody fusion (PLIF) |
|
Scrub
Circulate |
Shunt procedure/VP, VA/LP |
|
Scrub
Circulate |
Spine fusion |
|
Scrub
Circulate |
Ulnar nerve transfer |
|
Scrub
Circulate |
Ventriculography procedure/ventriculostomy |
|
Scrub
Circulate |
Ventriculostomy |
|
| |
| ORTHOPEDICS |
Scrub
Circulate |
Acetabular/pelvic ORIF |
|
Scrub
Circulate |
Achilles tendon repair |
|
Scrub
Circulate |
Amputation-leg, arm |
|
Scrub
Circulate |
Anterior cruciate ligament repair |
|
Scrub
Circulate |
Application of external fixators |
|
Scrub
Circulate |
Extremities |
|
Scrub
Circulate |
Pelvis |
|
Scrub
Circulate |
Application of halo traction |
|
Scrub
Circulate |
Arthroscopy |
|
Scrub
Circulate |
Ankle |
|
Scrub
Circulate |
Elbow |
|
Scrub
Circulate |
Knee |
|
Scrub
Circulate |
Shoulder |
|
Scrub
Circulate |
Arthrotomy |
|
Scrub
Circulate |
Bipolar/unipolar hips |
|
Scrub
Circulate |
Carpal tunnel release |
|
Scrub
Circulate |
Closed reduction fracture |
|
Scrub
Circulate |
Hand surgery with implants |
|
Scrub
Circulate |
Harrington rod instrumentation and/or Dwyer procedure |
|
Scrub
Circulate |
Heel cord lengthening |
|
Scrub
Circulate |
Hip compression nails & lag screws |
|
Scrub
Circulate |
Jewett |
|
Scrub
Circulate |
Kuntscher rod |
|
Scrub
Circulate |
Lottes |
|
Scrub
Circulate |
Total joint replacement – knee |
|
Scrub
Circulate |
Total joint replacement – hip |
|
Scrub
Circulate |
Total joint replacement – shoulder |
|
| |
| PLASTICS |
Scrub
Circulate |
Abdominal lipectomy |
|
Scrub
Circulate |
Blepharosplasty |
|
Scrub
Circulate |
Face lift |
|
Scrub
Circulate |
Mammoplasty |
|
Scrub
Circulate |
Augmenttion |
|
Scrub
Circulate |
Reduction |
|
Scrub
Circulate |
Liposuction |
|
Scrub
Circulate |
Otoplasty |
|
Scrub
Circulate |
Scar revisions |
|
Scrub
Circulate |
Skin grafting |
|
MY EXPERIENCE IS PRIMARILY IN: (Please indicate number of years)
|
| AGE SPECIFIC CRITERIA |
| Please select the box next to each age group that you have expertise in |
Newborn (birth – 30 days)
Infant (30 days – 1 year)
Toddler (ages 1 – 3 years)
Preschooler (ages 3 – 5 years)
Childhood (ages 6 – 12 years)
Adolescents (ages 12 – 21 years)
Young adults (ages 21 – 39 years)
Adults (ages 40 – 64 years)
Older Adults (ages 65 – 79 years)
Elderly (ages 80+ years) |
All the information on the preceding pages and this page is true and accurate to the best of my knowledge. By completing this form, I am authorizing Professional Staffing to release this information to the appropriated client facilities in consideration of employment as a registry, local traveler or full traveler. |
|
Please Enter Your Name and Date and then click the Submit Button
|
