Surgical Technician Checklist

Name: Date:

Years of Experience:

Directions for completing skills checklist:

The following is a list of equipment and/or procedures performed in renderingcare to patients. Please indicate your level of experience/proficiency with each area and, where applicable, the types of equipment and/or systems you are familiar with. Use the following key as a guideline:

A) Theory Only/No Experience--Didactic instruction only, no hands on experienceB) Limited Experience--Knows procedure/has used equipment, but has done so infrequently or not within the last six monthsC) Moderate Experience--Able to demonstrate equipment/procedure, performs the task/skill independently with only resource assistance needed.D) Proficient/Competent--Able to demonstrate/perform the task/skill proficiently without any assistance and can instruct/teach.

A. EAR, NOSE & THROAT A B C D

1. Adenoidectomy2. Caldwell - Luc3. Cleft lip/palate repair4. Closed reduction nasal fracture5. Ethmoidectomy6. Excision of salivary gland tumor7. Fenestration procedure8. Frontal flap sinus procedure9. Glossectomy10. Laryngectomy11. Mandibulectomy12. Mastoidectomy13. Maxillary advancement with hip graft14. Maxillectomy15. Myringoplasty16. Myringotomy/with PE tube insertion17. Nasal polypectomy18. Open reduction facial fracture19. Open reduction nasal fracture20. Parotidectomy21. Pharyngeal flap procedure22. Radical neck dissection23. Ranulectomy24. Rhinoplasty/septoplasty

25. Selective osteotomy of maxilla/mandible26. Sinus endoscopy27. Sinusotomy28. Stapedectomy29. Submucous resection30. Tonsillectomy31. Tracheostomy32. Tympanoplasty

B. ENDOSCOPIC PROCEDURES1. Bronchoscopy2. Colonoscopy3. Culdoscopy4. Cystoscopy5. Esophagoscopy6. Gastroscopy7. Hysteroscopy8. Laparoscopic procedures

a. Appendectomyb. Cholecystectomy/cholangiogramc. Colon resectiond. Hernia repaire. Nissen fundoplicationf. Salpingo-oophorectomyg. Tubal ligationh. Vaginal hysterectomy

9. Laryngoscopy & microlaryngoscopy10. Mediastinoscopy11. Pelviscopy12. Sigmoidoscopy13. Thoracoscopy

C. GENERAL SURGERY1. Abdominal perineal resection2. Adrenalectomy3. Anal fissurectomy4. Appendectomy5. Breast biopsy6. Colectomy7. Colostomy/ileostomy8. Gastrectomy9. Gastroplasty10. Hemorrhoidectomy11. Hepatic resection12. Herniorrhaphy - femoral, inguinal, umbilical13. Hiatal herniorrhaphy, transabdominal/transthoracic14. Hickman/Groshong/Portacath insertion15. Hydrocelectomy16. Imperforate anus reconstruction17. Lumbar sympathectomy

18. Omphalocele repair19. Pancreatectomy/pancreatogram20. Pilonidal cystectomy21. Portal caval shunt22. Pyloric stenosis23. Radical mastectomy24. Saphenous vein ligation and stripping25. Sentinel node biopsy26. Splenectomy27. Tenchkhoff catheter placement28. Thyroglossal duct cyst excision29. Thyroidectomy30. Tracheostomy31. Vagotomy

D. GYNECOLOGY1. Cesarean section2. Colpotomy3. Dilation and curettage (D & C)4. Hysterectomy, abdominal5. Hysterectomy, vaginal6. Marshall - Marchetti7. Marsupialization, Bartholin cyst8. Ovarian cystectomy9. Radium insertion10. Sacral spinus fixation11. Shirodkar procedure12. Suction curettage13. Vaginal reconstruction14. Vaginectomy/vulvectomy

E. NEUROLOGY1. A-V malformation2. Anterior cervical fusion3. Anterior laparoscopic spine procedures4. Anterior lumbar interbody fusion (ALIF)5. Burr holes for subdural hematoma6. Carotid ligation7. Cervical sympathectomy8. Craniectomy for decompression fracture9. Cranioplasty/craniotomy

a. Clipping of aneurysmb. Tumor excisionUsing stealth equipment (stealth craniotomy)

10. Discectomy11. Hypophysectomy12. Insertion nerve stimulators/medication pumps13. Laminectomy14. Myelomeningocele repair15. Pedicle screw insertion

16. Posterior lumbar interbody fusion (PLIF)17. Shunt procedure/VP, VA/LP18. Spine fusion - list systems you have used19. Ulnar nerve transfer20. Ventriculography procedure/ventriculoscopy21. Ventriculostomy

F. OPHTHALMOLOGY1. Cataract extraction with IOL2. Corneal transplant3. Dacryocystectomy4. Dacryocystorhinostomy5. Iridectomy6. Lid and muscle procedures7. Orbital implant8. Phaco emulsification9. Pterygium repair10. Recession resection11. Repair orbital blowout fracture12. Scleral buckle13. Vitrectomy

G. ORAL1. Closed reduction facial fractures/wiring2. Excision odontoma3. Extraction of deciduous teeth4. Extraction of impacted molars5. Fractured jaws, mandibular and zagomatic6. LeFort osteotomies7. Maxillary procedure with graft8. Pediatric dentistry9. Sagittal osteotomy10. Temporomandibular joint (TMJ) with arthroplasty11. TMJ exploration

H. ORTHOPEDICS1. Acetabular/pelvic ORIF2. Achilles tendon repair3. Amputation - leg, arm4. Anterior cruciate ligament repair5. Application of external fixators

a. Extremitiesb. Pelvis

6. Application of halo traction7. Arthroscopy

a. Ankleb. Elbowc. Kneed. Shoulder

Types :

8. Arthrotomy9. Bipolar/unipolar hips10. Bunionectomy11. Calcaneal reconstruction12. Capsulorrhaphy13. Carpal tunnel release14. Closed reduction fracture15. Hand surgery with implants16. Harrington rod instrumentation and/or Dwyer procedure17. Heel cord lengthening18. Hip compression nails & lag screws

a. Jewettb. Kuntscher rodc. Lottesd. Rushe. Schneiderf. Zimmerg. Others - list

19. Iliac crest bone graft20. Insertion Austin Moor hip prosthesis21. Intramedullary rods

a. Extractionb. Femoralc. Humerald. Insertione. Supracondylarf. Tibial

22. Laminectomy23. Olecranon bursa, excision of24. Open reduction of fracture, internal fixation with compression set25. Patellectomy26. Putti Platt/Bankart procedure/rotator cuff repair27. Reduction with compression sets28. Reimplantation of digits29. Repair hammer toes30. Sacro-iliac (SI) joint screws31. Sharrard procedure32. Spica cast, application of33. Spinal fusion34. Tendon transplants (hand and foot)35. Total joint replacements/revisions

a. Total hipb. Total kneec. Total shoulder

I. PLASTICS1. Abdominal lipectomy2. Blepharoplasty3. Face lift4. Mammoplasty

a. Augmentation

Types :

b. Reductionc. Tramflaps with reconstructive mammoplasty

5. Mentoplasty6. Otoplasty7. Pedicle grafts8. Scar revisions9. Split thickness skin grafting10. Tissue expanders

J. THORACIC & OPEN HEART1. Cervical rib excision2. Chamberlain procedure3. Closed thoracotomy4. Correction pectus excavatum5. Esophagectomy6. Heller procedure7. Mitral commissurotomy8. Open heart procedures

a. Mitral or aortic valve replacementb. Patent ductus arteriosusc. Septal defect repairsd. Tetrology of Fallot

9. Pacemaker implantation-endocardial10. Pacemaker implantation-myocardial11. Pericardiectomy12. Resection coarctation aorta13. Rib resection14. Thoracoplasty15. Tracheal resection16. Transthoracic diaphragmatic herniorrhaphy

K. TRANSPLANT1. Bone2. Bone marrow3. Corneal4. Harvesting5. Heart6. Kidney7. Liver8. Lung9. Multi-organ10. Pancreas11. Skin

L. TRAUMA1. Burns2. Gunshot/stab wounds

a. Abdomenb. Chest

c. Head3. Motor vehicle accidents (multiple injuries)4. Traumatic amputations

M. UROLOGY1. Adult circumcision2. Cystectomy3. Cystoscopy/ureteroscopy4. Hypospadias repair5. Implants: penile, testicular6. Lithotripsy7. Nephrectomy8. Nephrolithotomy9. Orchiopexy10. Prostatectomy

a. Perinealb. Supra-pubic

11. Pyeloplasty12. Radical node dissection13. Scott incontinence device14. TURP15. Ureterolithotomy16. Vasectomy17. Vasovasostomy18. Waterhouse procedure

N. VASCULAR1. A-V access graft2. Aortic aneurysm with graft replacement3. Endarterectomy/carotid - femoral4. Peripheral vascular bypass procedures5. Resection carotid aneurysm with graft6. Thrombectomy/embolectomy7. Vena cava filter/umbrella8. Vena cava ligation

O. EQUIPMENT1. Argon beam coagulator2. Bair Hugger3. Blood/fluid warmer4. Camera/video systems

a. Camera controllerb. Light sourcec. Printersd. VCRs

5. Cell saver6. Cidex soak7. Cryophthalmic unit8. Dermatome

a. Brownb. Padgettc. Zimmer

9. Disposable grounding pads10. Drills

a. 3-M Maxi driverb. Codman craniotomec. Hall air driverd. Hall dentale. Hall neurotomef. Midax Rex/Anspachg. Minidriverh. Stryker drills

(1) Large battery Stryker(2) Small battery Stryker

i. Surgairtomej. Synthes A-O Drill

11. Electrosurgical unit12. Emerson thoracic pump13. Ethylene oxide sterilizer - AMSCO14. Eye magnet15. Fiber optic luminator - list types Types :16. Flash autoclave - AMSCO17. Fracture tables

a. Chick table/Marquet tableb. Jackson tablec. Rush table/Skytron table

18. Hypo/hyperthermia unit19. Intestinal stapling devices

a. EEAb. GIAc. LDSd. TA

20. Kreiselman resuscitator21. Laser

a. CO2b. Eyec. Yagd. Other Types :

22. Mesh graft23. Microscopes, type Types :24. Nerve stimulator25. Nitrous oxide bank26. Ohio suction units27. Orthopedic arm board with drain28. Pleurevac disposable chest drainage29. Pneumatic tourniquet30. Sterad machine31. Steri-vac aeration cabinet, 3-M, portable32. Steris unit33. Suction unit, disposable34. Tele-thermometer

35. Ultrasonic cleaner - AMSCO36. Vac-pac positioner37. Vacuum curettage38. Washer sanitizer - AMSCO39. Washer sterilizer - AMSCO

AGE SPECIFIC PRACTICEA.Newborn/Neonate (birth - 30 days) D.Preschooler (3 - 5 years) G.Young adults (18 - 39 years)B.Infant (30 days - 1 year) E.School age children (5 - 12 years) H.Middle adults (39 - 64 years)C.Toddler (1 - 3 years) F.Adolescents (12 - 18 years) I.Older adults (64+)

EXPERIENCE WITH AGE GROUPS A B C D E G H IAble to adapt care to incorporate normal growth

and development.

Able to adapt method and terminology of patient instructions to

their age, comprehension and maturity level.

Can ensure a safe environment reflecting specific needs of

various age groups.

My experience is primarily in: (Please indicate number of years)

Medical year(s) Cardiothoracic year(s) Neuro year(s)

Neurological Cardiovascular Burn

Trauma Coronary care PACC

Other (specify)

The information I have given is true and accurate to the best of my knowledge. I hereby authorizePACE Medical Staffing, Inc. to release Surgical Technician Skills Checklist to client facilities of PNS inrelations to consideration of employment as a Traveler with those facilities.

Signature Date

Address Phone

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6167 Stoney Creek Drive Fort Wayne, IN 46825 Phone: 260-442-8884 Fax: 1-866-373-7744

www.pacemedcare.com

PACE Medical Staffing Inc.