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Surgical First Assist RN
First Assist RN
Name
*
Full Name
Date
MM slash DD slash YYYY
Self-Assessment Rating Scale
No Experience
Theory or observation only during the past 12 months
Limited Experience
Performed less than 12 times within the past 12 months and may need a review
Experienced
Performed at least once per month within the past 12 months and may need minimal assistance
Highly Skilled
Performed on at least a weekly basis over the past 12 months; proficient
First Assist RN
No Experience
Limited Experience
Experienced
Highly Skilled
Adenoidectomy
Caldwell - Luc
Cleft lip/palate repair
Closed reduction nasal fracture
Ethmoidectomy
Excision of salivary gland tumor
Fenestration procedure
Frontal flap sinus procedure
Glossectomy
Laryngectomy
Mandibulectomy
Mastoidectomy
Maxillectomy
Myringoplasty
Myringotomy/with PE tube insertion
Nasal polypectomy
Open Reduction Facial Fracture
Open Reduction Nasal Fracture
Parotidectomy
Perform - Morgan lens irrigation
Perform - Nasal Packing
Perform - Setup fluorescent/Woods lamp exam
Pharyngeal flap procedure
Radical Neck Dissection
Ranulectomy
Rhinoplasty/septoplasty
Selective osteotomy of maxilla/mandible
Sinus Endoscopy
Sinusotomy
Stapedectomy
Submucous resection
Tonsillectomy
Tracheostomy
Tympanoplasty
Trauma
No Experience
Limited Experience
Experienced
Highly Skilled
Gunshot/Stab wounds - Abdomen
Gunshot/Stab wounds - Chest
Gunshot/Stab wounds - Head
Motor Vehicle Accident (multiple injuries)
Traumatic Amputation
Orthopedics
No Experience
Limited Experience
Experienced
Highly Skilled
Acetabular/pelvic ORIF
Achilles tendon repair
Amputation of extremity
Anterior cruciate ligament repair
Application of external fixator
Application of halo traction
Arthoscopy - Ankle
Arthoscopy - Elbow
Arthoscopy - Knee
Arthoscopy - Shoulder
Arthotomy
Assessment - Circulation Checks
Assessment - Range of Motion
Assessment - Skin
Assist with placement of cast
Bunionectomy
Calcaneal reconstruction
Capsulorrhaphy
Carpal tunnel release
Closed reduction fracture
Equipment - Continous Passive Motion (CPM)
Equipment - Support Device - Transfer board
Hand Surgery with Implants
Harrington rod instrumentation and/or Dwyer procedure
Heel cord lengthening
Hip compression nails and lag screws - Jewett
Hip compression nails and lag screws - Kuntsher Rod
Hip compression nails and lag screws - Lottes
Hip compression nails and lag screws - Rush
Hip compression nails and lag screws - Schneider
Hip compression nails and lag screws - Zimmer
Iliac crest bone graft
Intramedullary rods - Extraction
Intramedullary rods - Humeral
Intramedullary rods - Femoral
Intramedullary rods - Supracondylar
Intramedullary rods - Tibial
Laminectomy
ORIF, internal fixation with compression set
Patellectomy
Putti Platt/Bankart procedure/rotator cuff repair
Reduction with compression sets
Reimplantation of digits
Repair hammer toes
Sacro-iliac (SI) joint screws
Sharrard procedure
Spica cast, application of
Spinal fusion
Tendons transplant (hand or foot)
Total joint replacement/revision - Total Hip
Total joint replacement/revision - Total Knee
Total joint replacement/revision - Total Shoulder
Emdoscopic
No Experience
Limited Experience
Experienced
Highly Skilled
Bronchoscopy
Colonoscopy
Culdoscopy
Cystoscopy
Gastroscopy
Esophagoscopy
Hysteroscopy
Laparoscopic Procedure - Appendectomy
Laparoscopic Procedure - Cholecystectomy/cholangiogram
Laparoscopic Procedure - Colon resection
Laparoscopic Procedure - Hernia repair
Laparoscopic Procedure - Nissen fundoplication
Laparoscopic Procedure - Salpingo-oophorectomy
Laparoscopic Procedure - Tubal ligation
Laparoscopic Procedure - Vaginal hysterectomy
Laryngoscopy & Microlaryngoscopy
Mediastinoscopy
Pelviscopy
Sigmoidoscopy
Thoracoscopy
General Surgery
No Experience
Limited Experience
Experienced
Highly Skilled
Abdominal perineal resection
Adrenalectomy
Anal fissurectomy
Appendectomy
Coloectomy
Breast Biopsy
Colostomy/ileostomy
Gastrectomy
Hemorrhoidectomy
Gastroplasty
Hepatic resection
Herniorrphaphy - femoral, inguinal, umbilical
Hiatal herniorrhaphy, transabdominal/transthoracic
Hickman/Groshong/Portacath insertion
Hydrocelectomy
Imperforate anus reconstruction
Lumbar sympathectomy
Omphalocele repair
Pancreatectomy/pancreatogram
Pilonidal cystectomy
Portal caval shunt
Radical mastectomy
Pyloric stenosis
Sentinel node biopsy
Saphenous vein ligation and stripping
Splenectomy
Tenchkoff catheter placement
Thyroglossal duct cyst excision
Thyroidectomy
Tracheostomy
Vagotomy
Gynecology
No Experience
Limited Experience
Experienced
Highly Skilled
Cesarean section
Colpotomy
Dilation and curettage (D & C)
Hysterectomy, Abdominal
Hysterectomy, Vaginal
Marshall - Marchetti
Marsupialization
Ovarian Cystectomy
Radium insertion
Sacral spinus fixation
Shirodkar procedure
Suction curettage
Vaginal Reconstruction
Vaginectomy/vulvectomy
Neurology
No Experience
Limited Experience
Experienced
Highly Skilled
Anterior cervical fusion
Anterior laparoscopic spine procedures
Anterior lumbar interbody fusion (ALIF)
A-V malformation
Burr holes for subdural hematoma
Carotid ligation
Cervical sympathectomy
Craniectomy for decompression fracture
Cranioplasty/craniotomy - clipping of aneurysm
Cranioplasty/craniotomy - Tumor excision
Disectomy
Hypophysectomy
Insertion nerve stimulators/medication pumps
Laminectomy
Myelomeningocele
Pedicle screw insertion
Posterior lumbar interbody fusion (PLIF)
Shunt procedure (VP, VA/LP)
Spine Fusion
Ulnar nerve transfer
Ventriculography procedure/ventriculoscopy
Ventriculostomy
Plastics
No Experience
Limited Experience
Experienced
Highly Skilled
Abdominal lipectomy
Blepharoplasty
Face Lift
Mammoplasty
Mentoplasty
Otoplasty
Pedicle grafts
Scar Revisions
Splint thickness skin grafting
Tissue Expanders
Thoracic Open Heart
No Experience
Limited Experience
Experienced
Highly Skilled
Chamberlain procedure
Closed thoracotomy
Correction pectus excavatum
Esophagectomy
Heller procedure
Mitral commissurotomy
Open Heart Procedures - Mitral or Aortic valve replacement
Open Heart Procedures - Patent ductus arteriosus
Open Heart Procedures - Septal defect repairs
Open Heart Procedures - Tetralogy of Fallot
Pacemaker implantation - endocardial
Pacemaker implantation - myocardial
Pericardiectomy
Resection coarctation aorta
Rib resection
Thoracoplasty
Tracheal resection
Transthoracic diaphragmatic herniorrhaphy
Urology
No Experience
Limited Experience
Experienced
Highly Skilled
Adult Circumcision
Cystectomy
Cystoscopy/Ureteroscopy
Implants: penile, testicular
Lithotripsy
Nephrectomy
Nephrolithotomy
Orchiopexy
Prostatectomy - Perineal
Prostatectomy - Supra-pubic
Pyeloplasty
Radical node dissection
Scott incontinence device
TURP
Ureterolithotomy
Vasectomy
Vasovasostomy
Waterhouse Procedure
Vascular
No Experience
Limited Experience
Experienced
Highly Skilled
Aortic aneurysm with graft replacement
A-V Access graft
Endarterectomy/carotid - femoral
Peripheral vascular bypass procedure
Resection carotid aneurysm with graft
Thrombectomy/embolectomy
Vena cava fliter/umbrella
Vena cava ligation
Laser
No Experience
Limited Experience
Experienced
Highly Skilled
CO2
Eye
Yag
Equipment
No Experience
Limited Experience
Experienced
Highly Skilled
Argon Beam Coagulator
Bair Hugger
Blood/Fluid Warmer
Camera/Video system - Camera Controller
Camera/Video system - Light Source
Cell Saver
Dermatome - Brown
Dermatome - Padgett
Dermatome - Zimmer
Disposable grounding pads
Drills - Codman Craniotome
Drills - 3M Maxi-driver
Drills - Hall air driver
Drills - Hall Neurotome
Drills - Midax Rex/Anspach
Drills - Minidriver
Drills - Stryker - Large Battery
Drills - Stryker - Small Battery
Electrosurgical Unit
Emerson Thoracic Pump
Ethylene oxide sterilizer - AMSCO
Eye magnet
Hoyer Lift
Flash Autoclave - AMSCO
Fracture Table - Chick table/Marquet table
Fracture table - Jackson table
Fracture table - Rush table/Skyton table
Hypo/Hyperthermia Unit
Intestinal Stapling Device- EEA
Intestinal Stapling Device- GIA
Intestinal Stapling Device- LDS
Intestinal Stapling Device- TA
K-Pads
Kreiselman resuscitator
Surgairtome
Synthes A-O Drill
Traction
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