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Proficiency Scale
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No Experience
2 =
Need Training
3 =
Able to perform with supervision
4 =
Able to perform independently
Assessment Section
Work Setting
✔ General OR
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✔ CVOR
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✔ Outpatient
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✔ Trauma
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✔ Peds-General OR
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✔ Peds-CVOR
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✔ First Assist
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✔ Scrub Experience
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General Surgery
✔ Abdominal Perineal Resection
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✔ Appendectomy/Cholescystectomy
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✔ Breast Biopsy
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✔ Colon Resection/Surgery
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✔ Gastrectomy
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✔ Gastric Bypass/Roux-en-Y
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✔ Hemorrhoidectomy
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✔ Herniorrhaphy - Inguinal, Ventral, Femoral, Umbilical
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✔ Laparoscopic General Surgeries
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✔ Laparoscopic Nissen Fundoplication
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✔ Mastectomy
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✔ Splenectomy
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✔ Thyroidectomy
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✔ Scrub General Surgery
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Cardiovascular
✔ Aorta Repair
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✔ Aorto-Bifemoral/Femoral-Pop Bypass Graft
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✔ Cardiac Bypass Surgery
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✔ Carotid Endarterectomy
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✔ Endoscopic Vascular Procedures
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✔ Femoral Popliteal Bypass Graft
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✔ Laparoscopic Cardiac Surgery
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✔ Robotic Assisted Cardiac Surgery
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✔ Valve Replacement/Repair
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✔ Ventricular Assist Device
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✔ Scrub CV Surgery
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Thoracic
✔ Endoscopic Thoracic Procedures
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✔ Esophagoogastrectomy
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✔ Mediastinotomy/Sternotomy
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✔ Thoracoscopy/Nuss Procedure
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✔ Thoracotomy
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✔ Scrub Thoracic Surgery
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Orthopedic
✔ Total Joint Replacement
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✔ Closed Reduction of Fracture
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✔ External Fixator
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✔ Cannulated Hip Screws
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✔ Bankhart Procedure
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✔ Birmingham Procedure
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✔ Arthroscopy
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✔ Anterior Cruciate Ligament Reconstruction
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✔ Open Reduction Internal Fixation
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✔ Scrub Orthopedics
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Neurological
✔ Craniotomy
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✔ Stereotactic Guided Brain Biopsy
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✔ Laminectomy
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✔ Laparoscopic Anterior Laminectomy
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✔ Insertion of Vagal Nerve Stimulator
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✔ Insertion of VP Shunt
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✔ Spinal Fusion
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✔ Anterior Cervical Discectomy with Fusion
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✔ Posterior Cervical Laminectomy
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✔ Scrub Neurological Surgery
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Genitourinary
✔ Vasicaurethropexy
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✔ Marshall Marchetti
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✔ Circumcision
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✔ Cystoscopy/Cystogram/Pyelogram
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✔ Prostatectomy
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✔ Nephrectomy
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✔ Orchidectomy/Orchidopexy
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✔ Ureterostomy
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✔ Laparoscopic Assisted GU Procedures
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✔ Robotic Assisted GU Procedures
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✔ Scrub GU Surgery
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Gynecological
✔ Abdominal Hysterectomy
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✔ Anterior Posterior Repair
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✔ C-Section
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✔ D & C
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✔ Laparoscopic Assisted Hysterectomy
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✔ Laparotomy with Microtuboplasty
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✔ Robotic Assisted GYN Procedures
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✔ Vaginal Delivery
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✔ Scrub Gyn Surgery
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Ear/Nose/Throat
✔ Laryngectomy
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✔ Mastoidectomy
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✔ Myringotomy with Insertion of Tubes
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✔ Radical Neck
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✔ Septoplasty
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✔ Tonsillectomy & Adenoidectomy
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✔ Tracheostomy
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Untitled Section
✔ Tympanoplasty
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✔ Scrub ENT Surgery
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Craniofacial/Oral
✔ Craniectomy
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✔ Craniofacial Reconstruction
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✔ Dental Surgery
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✔ Leforte 1 Maxillary/Sagittal Osteotomy
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✔ ORIF Mandibular Fracture
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✔ Otoplasty
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✔ Reconstruction of Ear
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✔ Removal of Arch Bars
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✔ Repair of Cleft Lip, Nose, Palate
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✔ Rhinoplasty
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✔ Scrub Craniofacial/Oral
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Plastic
✔ Blephoroplasty
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✔ Breast Reconstruction with Implant
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✔ Breast Reduction Mammoplasty
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✔ Face Lift
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✔ Mastectomy with Tram Flap Reconstruction
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✔ Split Thickness Skin Graft
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✔ Suction Lipectomy
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✔ Scrub Plastics
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Transplants
✔ Heart
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✔ Lung
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✔ Liver
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✔ Pancreas
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✔ Eye
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✔ Organ Donation
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✔ Scrub Transplants
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General Surgery
✔ Anal Fistulectomy/Anoplasty
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✔ Appendectomy/Cholecystectomy
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✔ Biopsy (Mass, Muscle, Lymph Node)
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✔ Bronchoscopy
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✔ Colostomy
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✔ Esophagogastroduodenoscopy w/ Biopsy
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✔ Esophagoscopy
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✔ Exploratory Laparotomy
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✔ Flexible Sigmoidoscopy
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✔ Fundoplication
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✔ Gastrostomy
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✔ Herniorrhaphy
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✔ Insertion of Port-a-Cath, Hickman, Broviac
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✔ Laparascopic General Surgery Procedures
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✔ Liver Biopsy
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✔ Percutaneous Endoscopic Gastrostomy
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✔ horacoscopy/Nuss Procedure
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✔ Scrub Peds General Surgery
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Genitourinary
✔ Circumcision
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✔ Cystoscopy/Cystogram/Pyelogram
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✔ Hydrocelectomy
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✔ Nephrectomy
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✔ Orchidectomy/Orchidopexy
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✔ Repair of Hypospadias
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✔ Retrograde Pyelogram
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✔ Ureterostomy
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✔ Scrub Peds GU
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Neuro
✔ Craniotomy
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✔ Insertion of Vagal Nerve Stimulator
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✔ Insertion of VP Shunt
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✔ Scrub Peds Neuro
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Cardiac/Vascular
✔ Arterial Switch
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✔ ASD/VSD Repair
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✔ Atrial Septectomy
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✔ Bidirectional Glenn
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✔ BT Shunt
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✔ ECMO Insertion/Decannulation (Cardiac)
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✔ Fontan Procedure
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✔ Norwood Procedure
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✔ Pacemaker
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✔ PDA Ligation
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✔ Repair of Coarctation of Aorta
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✔ Ross Procedure
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✔ Tetralogy of Fallot Repair
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✔ Valve Repair/Replacement
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✔ Ventricular Assist Device
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✔ Scrub Peds Cardiac/Vascular
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Transplant
✔ Heart
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✔ Kidney
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✔ Liver/Pancreas
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✔ Lung
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★
✔ Organ Donation
*
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★
✔ Scrub Peds Transplant
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Ophthalmology
✔ Corneal Transplant
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★
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✔ Dacrocystorhinostomy
*
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★
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★
✔ Excision of Chalazion
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✔ Eye Muscle Surgery
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✔ Levator Resection
*
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✔ Orbitotomy of Eye
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✔ Repair of Ptosis
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✔ Scrub Peds Opthalmology
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Ear/Nose/Throat
✔ Cochlear Implant
*
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✔ Laryngotracheoplasty
*
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★
✔ Myringotomy with Tubes
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✔ Septoplasty
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✔ Suspension Microlaryngoscopy
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✔ Tonsillectomy & Adenoidectomy
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✔ Tracheostomy
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✔ Turbinate Reduction
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✔ Tympanoplasty/Tympanomastoidectomy
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★
✔ Scrub Peds ENT
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Craniofacial/Oral/Plastics
✔ Craniectomy
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★
★
✔ Craniofacial Reconstruction
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★
★
★
✔ Dental Surgery
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★
✔ Leforte 1 Maxillary/Sagittal Osteotomy
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★
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★
✔ Mandibular Osteotomy
*
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★
✔ ORIF Mandibular Fracture
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✔ Otoplasty
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✔ Reconstruction of Ear
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★
✔ Repair of Cleft Lip, Nose, Palate
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★
✔ Rhinoplasty
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★
✔ Skin Graft
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★
✔ Scrub Peds C-Fl/Oral/Plastics
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Orthopedics
✔ Acetabuloplasty/Triple Innominate
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★
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★
✔ Arthroscopy of Knee, Wrist, Shoulder
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✔ Closed Reduction, Percutaneous Pin
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✔ External Fixator (Ilizarov/Orthofix)
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✔ ORIF Shoulder, Humerus, Tibia, Femur
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✔ Osteotomy/VDRD/Calcaneal/Metatarsal
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★
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✔ Spinal Fusion/Spinal with Instrumentation
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★
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✔ Tendoachilles Lengthening
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✔ Scrub Peds Ortho
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OR Equipment
✔ Electrocautery (ESU)
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★
★
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✔ Laparoscopy Systems
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★
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✔ Neuro
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✔ OR Fracture Tables (List Types)
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✔ Orthopedic Total Joint Systems
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★
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✔ Power Equipment
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★
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✔ Robotics Systems (List Types)
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★
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✔ Spinal Fusion Instrumentation
*
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Professional Knowledge and Skills
✔ Malignant Hyperthermia Protocol
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★
★
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★
✔ Administer and Monitor Moderate Sedation
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★
✔ Universal Protocol for Wrong Site Surgery
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★
✔ National Patient Safety Goals/Core Measures
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★
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✔ Fall Risk Assessment/Prevention
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★
★
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★
✔ Pressure Ulcer Risk Assessment/Prevention
*
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★
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★
★
✔ Restraints/Use of Least Restrictive Device
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★
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✔ Age Specific/Population-Based Care
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★
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✔ Isolation Precautions
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★
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✔ Infection Prevention
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★
EMR
✔ Epic
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★
★
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✔ Cerner
*
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★
★
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★
✔ Eclipsys
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★
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✔ McKesson
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✔ Meditech
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★
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✔ Other Computerized System
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✔ Computerized Physician Order Entry
*
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★
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