Instructions: This checklist is
meant to serve as a general guideline for our client facilities as to the
level of your skills within your nursing specialty. Please use the scale
(PROFICIENCY)
1 = No Experience
2 = Need Training
3 = Able to perform with supervision
4 = Able to perform independently
(FREQUENCY)
1 = Never performed observed only
2 = Less than 6 times per year
3 = 1-2 times per month
4 = Daily or Weekly
PROFICIENCY / FREQUENCY
PROFICIENCY
FREQUENCY
Abdominal - Perineal Resection
Mitral Valve Repair/Replacement
Multiple Valve Transposition
Ventricular aneurysm Repair
Intra-Aortic Balloon Insertion
Heartport or Similar CABG
Femoral Artery Cannulation
Abdominal Aortic Aneurysm
Femoral-Popliteal By-Pass Graft
SCRUB LAPARASCOPIC PROCEDURES
Inguinal/Ventral hernia Repair
Bowel Rescetion/Colostomy
Abdominal Aortic Aneurysm
Femoral-Popliteal By-Pass Graft (Insitu)
Femoral-Popliteal By-Pass Graft (Graph)
Portacath, Tesio, Hickman
Intra-Operative Angioplasty
Subclavian/Carotid By-Pass
Harrington Rod or Similar
Mini Fragment Screws & Plates
Laparoscopic Asst'd Vaginal Hysterectomy
Anterior/Posterior Repair
MMK (Marshall Marchetti Krantz)
BLT (Bilateral Tubal Ligation)
Radical Lymph Node Dissection
Insertion Penile Prosthesis
Cervical Laminectomy (Anterior)
Cervical Laminectomy (Posterior)
Lumbar Laminectomy, Discectomy
Percutaneous Micro Discectomy
Transphenoidal Hypophysectomy
Harrington Rod or Similar
Organ Procurements (Harvest)
Age Specific Competencies
Preschooler (ages 2-5 years)
Childhood (ages 6-12 years)
Adolescents (ages 13-21 years)
Young Adults (ages 22-39 years)
Adults (ages 40-64 years)
Older Adults (ages 65-79 years)