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OR RN
OR 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
General Surgery
No Experience
Limited Experience
Experienced
Highly Skilled
Abdominal perineal resection
Adrenalectomy
Bowel Resection
Cholecystectomy
Colostomy/Ileostomy
Gastrectomy
Hemicolectomy
Hepatic resection
Herniorrhaphy - Femoral/inguinal
Hiatal herniorraphy - Transabdominal
Pancreatectomy
Organ procurement
Radical mastectomy
Saphenous vein ligation and stripping
Splenectomy
Thyroidectomy
Tracheostomy
Whipple procedure
Laparoscopic Procedures
No Experience
Limited Experience
Experienced
Highly Skilled
Appendectomy
Cholecystectomy
Colon resection
Hernia repair
Hysterectomy
Gynecology
No Experience
Limited Experience
Experienced
Highly Skilled
Caesarean section
Dilation & curettage
Hysterectomy - Vaginal
Hysterectomy - Abdominal
Laser surgery
Radium insertion
Salpingo-oophorectomy
Shirodkar procedure
Termination of pregnancy
Tubal ligation
Vaginectomy
Vaginal reconstruction
G.U. and CYSTO
No Experience
Limited Experience
Experienced
Highly Skilled
Circumcision
Cystoscopy/cystostomy
Cystectomy
Hypospadius repair
Ileal loop
Lithotripsy
Nephrectomy
Orchiectomy
Penile implant
Prostatectomy
Ureterolithotomy
TURP/TURB
Vasectomy
Orthopedic
No Experience
Limited Experience
Experienced
Highly Skilled
Amputation - Leg/arm
Application of halo traction
Arthroscopy/arthrotomy
Closed pinning and reduction of extremities
External compression devices
Insertion of finger prosthesis
Total joint replacement - Knee, hip, shoulder
Spinal fusion - Harrington rods
Spica cast application
ORIF - Shoulder, hip, humerus, etc.
Repair of dislocation
Patellectomy
Tendon implants and reanastomosis
Neurosurgery
No Experience
Limited Experience
Experienced
Highly Skilled
Anterior cervical fusion
Burrholes for subdural hematoma
Craniotomy
Laminectomy
Meningocele repair
Shunt procedures - VP/VA
Plastics
No Experience
Limited Experience
Experienced
Highly Skilled
Abdominoplasty/abdominal lipectomy
Augmentation mammoplasty
Cleft lip/palate repair
Dermabrasion
Digital flexor tendon repair
Face lift
Liposuction
Myelomeningocele repair
Otoplasty
Rhinoplasty
Reduction of facial fracture
Skin grafting
Eye
No Experience
Limited Experience
Experienced
Highly Skilled
Cataracts
Canthotomy
Correction of ectropian/entropian
Corneal transplant
Enucleation
Excision of chalazion
IOI implants
Lacrimal duct probing
Refractive keratoplasty
Repair of retinal detachment
Vitrectomy
Ear, Nose, & Throat
No Experience
Limited Experience
Experienced
Highly Skilled
Caldwell-Luc
Ethymoidectomy
Frontal flap sinus procedure
Laryngectomy
Laryngoscopy
Nasal polypectomy
Open reduction facial fractures
Radical neck
Tonsillectomy and Adenoidectomy
Myringotomy
Mastoidectomy
Tympanoplasty
Stapedectomy
Thoracic
No Experience
Limited Experience
Experienced
Highly Skilled
Chest tube set-up
Hiatal hernia
Pneumonectomy/lobectomy
Sternal splitting
Thoracotomy
Bronchoscopy
Lung/wedge resection
Endoscopy
No Experience
Limited Experience
Experienced
Highly Skilled
Bronchoscopy
Cystoscopy
Gastroscopy
Colonoscopy
Cardiovascular
No Experience
Limited Experience
Experienced
Highly Skilled
A-V shunts
Aortic aneurysm, abdominal
Aorto-femoral bypass
Graft insertion
Cardiac valve replacement
Coronary artery bypass graft - On pump
Endarterectomy - Carotid/femoral
Femoral - Popliteal bypass
External temporary pacemaker
Internal pacemaker insertion
Intra-aortic balloon pump catheter
Patent ductus repair
Pericardial windows
Portasystemic shunt
No Experience
Limited Experience
Experienced
Highly Skilled
Repair of septal defects
Thrombectomy
Vena cava ligation
Transplants
No Experience
Limited Experience
Experienced
Highly Skilled
Eye
Kidney
Liver
Lung
Heart
Pancreas
Equipment
No Experience
Limited Experience
Experienced
Highly Skilled
Robotics
Fracture tables
Video systems
CUSA
Cell saver
PACS diagnostics
Drills
Stapling devices
Ventilators
Cardiac monitors
Crash carts
Defibrillators
Sterilization of Equipment
No Experience
Limited Experience
Experienced
Highly Skilled
Log
Biological indicators
Autoclave operation
High level
STERIS
Steam
Gas
Flash
Miscellaneous
No Experience
Limited Experience
Experienced
Highly Skilled
Crash cart
Universal protocol
Patient identification
Hand-off communication
Standard precautions
Isolation precautions
Pediatric respiratory/cardiac arrest
Adult respiratory/cardiac arrest
Automated med dispensing systems
Electronic documentation
Age Experience
No Experience
Limited Experience
Experienced
Highly Skilled
Newborn/neonate (birth - 30 days)
Infant (1mo - 1yr)
Toddler (1 - 3 yrs)
Preschooler (3 - 5 yrs)
School age child (5 - 12 yrs)
Adolescents (12 - 18 yrs)
Young adults (18 - 39 yrs)
Middle adults (39 - 64 yrs)
Older adults (64 - 79 yrs)
Elderly adults (over 79+ yrs)
Lararoscopic Procedures
No Experience
Limited Experience
Experienced
Highly Skilled
Cholecystectomy
Appendectomy
Hernia repair
Colon resection
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