SELF EVALUATION
OR
SKILLS PROFICIENCY CHECKLIST
![[HRule Image]](../images/div.gif){kind=small}
Print this form and fax or mail:
Fax to: (505) 797-3822
Mail to: 5150 San Francisco RD NE Albuquerque, NM 87109
Last Name:
First Name:
Middle Initial:
|
Years Experience |
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DIRECTIONS: Place an x in the box that best describes your level of proficiency for each of the skills presented.
LEVELS OF PROFICIENCY KEY:
| 0 = |
No Experience |
3 = |
Performs well, can act as a resource person |
|
| 1 = |
Minimal Experience, need supervision |
4 = | Scrub | |
| 2 = |
Can perform without supervision |
5 = | Circulate | |
| General Skills: | 0 | 1 | 2 | 3 | 4 | 5 | Thoracic & Open Heart: | 0 | 1 | 2 | 3 | 4 | 5 | |
| Radical Mastectomy | Pacemaker Insertion | |||||||||||||
| Rectal Cases | Thoracotomy | |||||||||||||
| Abdominal – Perineal Resection | Open Heart Procedures | |||||||||||||
| Cholecystectomy | ASD – Atrial Septal Defect | |||||||||||||
| Minor Cases Set – Up (breast biopsies, hernias) | VSD – Ventral or Ventricular Septal Defect | |||||||||||||
| Nissen Fundoplication | Mitral or Aortic Valve Replacement | |||||||||||||
| Thyroidectomy | Tetrology of Follet | |||||||||||||
| Leveen – Peritoneal Shunt | Patent Ductus Arteriosis | |||||||||||||
| Colon Resection | Chamberlain Procedure | |||||||||||||
| Staging Laporotomy | OME | |||||||||||||
| Vascular: | Neurology: | |||||||||||||
| Aortia’illiac/Femoral Graft | Cervical Laminectomy | |||||||||||||
| Arotic Aneurysm | Transphenoid Hypothypectomy | |||||||||||||
| Thrombectomy | Carotid Endartectomy | |||||||||||||
| Femoral-Popliteal Graft | VA and VP Shunt | |||||||||||||
| Carotid Endartectomy | Acoustic Neuroma | |||||||||||||
| Mohin-Uddin Umbrella | Craniotomy | |||||||||||||
| Leaking Ruptured Aneurysm | Lumbar Laminectomy | |||||||||||||
| Burr Holes (subdural hematoma) | ||||||||||||||
| Trauma: | ||||||||||||||
| Gunshot Wounds | Orthopedics: | |||||||||||||
| Chest | Total Joint Replacement | |||||||||||||
| Abdomen | Arthroscopy | |||||||||||||
| Motor Vehicle Accidents (multiple injuries) | Harrington Rod Insertion | |||||||||||||
| Traumatic Amputations | Dwyer Anterior Fusion | |||||||||||||
| I.M. Rodding | ||||||||||||||
| Urology: | Zimmer Hip Compression | |||||||||||||
| Nephrectomy | Reduction with Compression Sets | |||||||||||||
| Pyelolithotomy | Fracture Table Use | |||||||||||||
| Scott Penile Prosthesis | Hand Surgery – Including Implants | |||||||||||||
| Soot Incontinence Device | ||||||||||||||
| Vasovasostomy | Gynecology: | |||||||||||||
| Radical Node Dissection | Abdominal Hysterectomy | |||||||||||||
| Vaginal Hysterectomy | ||||||||||||||
| Oral: | Laporoscopy | |||||||||||||
| TMJ Exploration | Marshall Marchetti Krantz | |||||||||||||
| LaFort Osteotomies | Tubopiasty | |||||||||||||
| Maxillary Procedure with Graft | Cholecystectomy | |||||||||||||
| TMJ with Arthroplasty | C-Sections | |||||||||||||
| Fractured Jaws, Mandibular and Zagomatic | ||||||||||||||
| Pediatrics: | ||||||||||||||
| Transplant: | Pediatric Lap | |||||||||||||
| Cadaver Kidney Recovery (Harvest) | Pediatric Inguinal Hernia | |||||||||||||
| Kidney Transplant Recipient | Plloric Stenosis | |||||||||||||
| Kidney Transplant Donor | Bronchoscopy | |||||||||||||
| Brachio Axillary Darcon Fistula | ||||||||||||||
| A-V Fistula Shunt | Opthalmology: | |||||||||||||
| Trenckhoff Catheter Placement | Phaco Emulaification | |||||||||||||
| Spleenectomy | ICLE | |||||||||||||
| ECLE | ||||||||||||||
| Ear, Nose and Throat: | Retina | |||||||||||||
| T and A Myringotomies | Lid and Muscle Procedures | |||||||||||||
| Ear Cases | Enucieation | |||||||||||||
| Tympanopiasty | ||||||||||||||
| Mastoidectomy | Plastics: | |||||||||||||
| Stapedectomy | Augmentation Mammoplasty | |||||||||||||
| Acoustic Neuroma | Reduction Mammoplasty | |||||||||||||
| Rhinoplasty | Rhinoplasty | |||||||||||||
| Frontal Sinus Trephing | Cleft Lip and Plasty Repair | |||||||||||||
| Endoscopies | Abdominal Lipectomy | |||||||||||||
| Vocal Cord Stripping | Skin Grafts | |||||||||||||
| Otoplasty | ||||||||||||||
Submitted by: Date:
Phone / Email:
© Rapid Temps, Inc., rev Feb-2000
