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Surgical Tech
Surgical Tech
Name
First
Last
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
Experience with the Following Ages:
No Experience
Limited Experience
Experienced
Highly Skilled
Newborn/neonate (birth-30 days)
Infant (1 mo-1 yr)
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 (79+ yrs)
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 herniorrhaphy-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
Hysterectomy
Cholecystectomy
Appendectomy
Hernia repair
Colon resection
Gynecology
No Experience
Limited Experience
Experienced
Highly Skilled
Caesarean section
Dilation and curettage
Hysterectomy - Vaginal
Hysterectomy - Abdominal
Laser surgery
Radium insertion
Salpingo-oopherectomy
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
Arthroscop/arthrotomy
Closed pinning and reduction of extremities
External compression devices
Insertion of finger prosthesis
Total joint replacement - Knee
Total joint replacement - Hip
Total joint replacement - Shoulder
Spinal fusion - Harrington rods
Spica cast application
Open reduction and internal fixation (ORIF)
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
Face lift
Skin grafting
Abdominoplasty/abdominal lipectomy
Augmentation mammoplasty
Cleft lip/palate repair
Dermabrasion
Digital flexor tendon repair
Liposuction
Myelomeningocele repair
Otoplasty
Rhinoplasty
Reduction of facial fracture
Eye
No Experience
Limited Experience
Experienced
Highly Skilled
Excision of chalazion
Canthotomy
Correction of ectropian/entropian
Corneal transplant
Enucleation
IOI implants
Lacrimal duct probing
Refractive keratoplasty
Repair of retinal detachment
Vitrectomy
Ear, Nose, and Throat
No Experience
Limited Experience
Experienced
Highly Skilled
Caldwell-Luc
Ethymoidectomy
Frontal flap sinus procedure
Laryngectomy
Open reduction facial fractures
Radical neck
Tonsillectomy and adenoidectomy
Myringotomy
Mastoidectomy
Tympanoplasty
Stapedectomy
Nasal polypectomy
Laryngoscopy
Thoracic
No Experience
Limited Experience
Experienced
Highly Skilled
Chest tube setup
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-poplital bypass
External temporary pacemaker
Internal pacemaker insertion
Intro-aortic balloon pump catheter
Patent ductus repair
Pericardial windows
Repair of septal defects
Thrombectomy
Vena cava ligation
Transplants
No Experience
Limited Experience
Experienced
Highly Skilled
Pancreas
Heart
Lung
Liver
Kidney
Eye
Equipment
No Experience
Limited Experience
Experienced
Highly Skilled
Robotics
Fracture tables
Video systems
CUSA
Cell saver
PACS diagnostics
Electrocautery
Drills
Saws
Stapling devices
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
Universal protocol
Crash cart
Patient identification
Hand-off communication
Standard precautions
Isolation precautions
Pediatric respiratory/cardiac arrest
Adult respiratory/cardiac arrest
Electronic documentation
Signature
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