ADEX Medical Staffing - Surgical Tech Skills Checklist

Surgical Tech Skills Checklist

This assessment is for determining your experience in the below outlined clinical areas. This checklist will not be used as a determining factor in accepting your application for employment with ADEX Medical Staffing, LLC.

Proficency Scale:

1 = No Experience - Theory only

2 = Limited Experience - Infrequent

3 = Moderate Experience - Able to perform independently

4 = Proficient - Able to perform proficiently and instruct

Frequency Scale:

1 = Never Observed

2 = Less than 6 times a year

3 = 1 or 2 Times a Month

4 = Daily or Weekly

Personal Information
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	Proficiency				Frequency
General Surgery	1	2	3	4	1	2	3	4
AKA/BKA (amputation
Radical Mastectomy
Abdominal-Perineal Resection
Cholecystectomy (Open)
Exploratory Laparotomy
Appendectomy
Laparoscopic Procedure-Cholecystectomy
Laparoscopic Procedure-Appendectomy
Laparoscopic Procedure-Hernia
Laparoscopic Procedure-Nissan
Laparoscopic Procedure-Colectomy
Gastrectomy
Inguinal/Ventral Hernia Repair
Spienectomy
Bowel Resection/Colostomy
Thyroidectomy
Rectal Procedures
Esophagascopy/Gastroscopy
Pediatric Case-Inguinal Hernia Repair
Pediatric Case-Pyloric Stenosis
Pediatric Case-Circumcision
Pediatric Case-Exploratory Laparotomy

	Proficiency				Frequency
Vascular Surgery	1	2	3	4	1	2	3	4
Carotid Endarterectomy
Abdominal Aortic Aneurysm
Femoral-Popliteal By-pass Graft (Insitu)
Femoral-Popliteal By-pass Graft (Graph)
Portacath, Tesio, Hickman
AV Shunt
Thrombecomy
Pacemaker Insertion
Arterial Stenting/Intra-Operative Angioplasty
Subclavin/Carotid By-pass

	Proficiency				Frequency
Cardiac/Thoracic/Vascular	1	2	3	4	1	2	3	4
Coronary Artary By-pass
Mitral Valve Repair/Replacement
Aortic Valve Replacement
Multiple Valve Transposition
Septal Defects
Ventricular Aneurysm Repair
Bring Back Heart
Pericardial Window
Intra-Aortic Balloon Insertion
Heartport or Similar CABG
Thoraco approach Mid-Cab
Aortic Arch Replacement/Valve Conduit
Mechanical Heart/LVAD
Pediatric Hearts
Tetrology of Fallot
Chamberlain Procedure
Femoral Artery Cannulation
AICD Insertion
Saphenous Vein Harvest
Endoscopic Vein Harvest
Gastric Artery Harvest
Radial Vein Harvest
Carotid Endarterectomy
Abdominal Aortic Aneurysm
Femoral-Popliteal By-pass Graft
Thrombectomy
AV Shunt
Pacemaker Insertion
Insertion Vena cava Filter
Portacath, Tesio, Hickman Placement
Thoracotomy
Thoracoscopy
Insertion Chest Tubes
Esophageal Repair
Pneurnonectorny/Lobectomy
Mediastinodcopy
Desendind Aortic Repair
Arterial Stenting/Intra-Operative Angiopiasty

	Proficiency				Frequency
Orthopedics	1	2	3	4	1	2	3	4
Total Hip Replacement
Bipolar Hip
Compression Hip Screw
Total Knee Replacement
Knee Arthoscopy
ACL Knee Repair
Harrington Rod or Similar
I.M. Rodding
Hand & Foot Procedures
Mini, Standard, Large Fragment Screws & Plates
External Fixation
Shoulder Repair
Sholder Arthoscopy
Spinal Fusion
Cast Application
Fracture Table Set-up
Drills, Saws and Reamers

	Proficiency				Frequency
Gynecology	1	2	3	4	1	2	3	4
D&C
Diagnostic Laparascope
Laparoscopic Assisted Vaginal Hysterectomy
Abdorninal Hysterectorny
Varinal Hysterectorny
Anterior/Posterior Repair
MMK(Marshall Marchetti Krantz)
Tuboplasty
BTL(Bilateral Tubal Ligation)
C-Sections

	Proficiency				Frequency
Urology	1	2	3	4	1	2	3	4
Radical Prostatectomy
Radical Lymph Node Dissection
Insertion Penile Prostesis
Hydrocelectomy
Cystoscopy
Ureterosocpy
TURP/TURST
Ultrasonic Lithotripsy

	Proficiency				Frequency
Neurology	1	2	3	4	1	2	3	4
Cervical Laminectomy(Anterior)
Cervical Laminectomy(Posterior)
Lumbar Laminectomy, Discectomy
Percutaneous Micro Discectomy
Craniotomy For Tumor
Craniotomy For Aneurysm
Burr Holes
VP Shunts
Transphenoidal Hypothypectomy
Carpal Tunnel Repair
Harrington Rod or Similar

	Proficiency				Frequency
Plastics	1	2	3	4	1	2	3	4
Mammoplasty
Facelifts
Skin Grafts
Rhinopiasty
Cleft Lip Repair
Abdorninalplasty
Blepharopiasty
Otoplasty
Muscle Flaps

	Proficiency				Frequency
E.N.T.	1	2	3	4	1	2	3	4
Middle Ear Cases
T&A
Myringotomy
Tympanoplasty
Radical Neck Dissection
Septoplasty
Sinus Endoscopy

	Proficiency				Frequency
Trauma Surgery	1	2	3	4	1	2	3	4
Transplant Surgery
Organ Procurement(Harvest)

	Proficiency				Frequency
Thoracic Surgery	1	2	3	4	1	2	3	4
Thoracotomy
Thoracoscopy
Insertion Chest Tubes
Esophageal Repair
Pneumonectomy/Lobectomy

	Proficiency				Frequency
Age Specific Skills	1	2	3	4	1	2	3	4
Newborn (birth-30 days)
Adolescents (12 - 18 years)
Infant (30 days - 1 year)
Young Adults (18 - 39 years)
Toddler (1 - 3 years)
Middle Adults (39 - 64 years)
Preschooler (3 - 5 years)
Older Adults (64+ years)
School Age (5 - 12 years)

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The information represented above is true and correct to the best of my knowledge. I authorize ADEX Medical Staffing, LLC to share this skills checklist with its clients.
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Form Reviewed by ADEX Clinician - 11/16/2010