Pediatric OR Skills Checklist

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Skills Checklist

Let’s assess your clinical skills and experience. Fill out this checklist to get one step closer to your next opportunity.

1

= No theory and/or experience
2

= Limited Experience
3

= Experienced/minimal support needed to perform
4

= Proficient

Age of Patients Cared For
Newborn/Neonate (birth to 30 days)*
- 1
- 2
- 3
- 4
Infant (1 month to 1 year)*
- 1
- 2
- 3
- 4
Toddler (1 year to 3 years)*
- 1
- 2
- 3
- 4
Preschooler (3 years to 5 years)*
- 1
- 2
- 3
- 4
School Age Child (5 years to 12 years)*
- 1
- 2
- 3
- 4
Adolescents (12 years to 18 years)*
- 1
- 2
- 3
- 4
Young Adults (18 years to 39 years)*
- 1
- 2
- 3
- 4
ENT/Plastics
Tonsillectomy/Adenoidectomy*
- 1
- 2
- 3
- 4
Tympanostomy/Tube Insertion*
- 1
- 2
- 3
- 4
Tympanoplasty/Tympanomastoidectomy/Micro-Ear Surgery*
- 1
- 2
- 3
- 4
Cochlear/Baha Implant*
- 1
- 2
- 3
- 4
Otoplasty/Microtia Repair*
- 1
- 2
- 3
- 4
Microlaryngoscopy/Bronchoscopy*
- 1
- 2
- 3
- 4
Laryngoscopy with Suspension/Intervention*
- 1
- 2
- 3
- 4
Tracheostomy*
- 1
- 2
- 3
- 4
Thyroidectomy*
- 1
- 2
- 3
- 4
Radical Neck Dissection*
- 1
- 2
- 3
- 4
Cleft Lip Repair*
- 1
- 2
- 3
- 4
Cleft Palate Repair/Alveolar Bone Graft*
- 1
- 2
- 3
- 4
Rhinoplasty*
- 1
- 2
- 3
- 4
Septoplasty*
- 1
- 2
- 3
- 4
Sinusectomy*
- 1
- 2
- 3
- 4
Mandibular Distraction*
- 1
- 2
- 3
- 4
Reduction of Facial Fractures*
- 1
- 2
- 3
- 4
Lasers*
- 1
- 2
- 3
- 4
Skin Grafting*
- 1
- 2
- 3
- 4
Orthopedics
Closed Reduction Internal Fixation (humerus, femur, etc.)*
- 1
- 2
- 3
- 4
Open Reduction Internal Fixation (humerus, femur, etc.)*
- 1
- 2
- 3
- 4
External Fixation Application*
- 1
- 2
- 3
- 4
Epiphysiodesis*
- 1
- 2
- 3
- 4
Arthoscopy (hip, knee, shoulder, etc.)*
- 1
- 2
- 3
- 4
Periacetabular Osteotomy (PAO)*
- 1
- 2
- 3
- 4
Total Joint Replacement*
- 1
- 2
- 3
- 4
Slipped Capital Femoral Epiphysis (SCFE)*
- 1
- 2
- 3
- 4
Ortho Trauma*
- 1
- 2
- 3
- 4
Bone Biopsy*
- 1
- 2
- 3
- 4
Tumor Resection/Limb/Joint Reconstruction*
- 1
- 2
- 3
- 4
Amputation*
- 1
- 2
- 3
- 4
Application of HALO Traction*
- 1
- 2
- 3
- 4
Spinal Fusion*
- 1
- 2
- 3
- 4
Eyes
Excision of Chalazion*
- 1
- 2
- 3
- 4
Canthotomy*
- 1
- 2
- 3
- 4
Strabismus*
- 1
- 2
- 3
- 4
Correction of Ectropion/Entropion*
- 1
- 2
- 3
- 4
Corneal Transplant*
- 1
- 2
- 3
- 4
Enucleation*
- 1
- 2
- 3
- 4
IOL Implants*
- 1
- 2
- 3
- 4
Lacrimal Duct Probing*
- 1
- 2
- 3
- 4
Repair of Retinal Detachment*
- 1
- 2
- 3
- 4
Vitrectomy*
- 1
- 2
- 3
- 4
Laser Treatment for Retinopathy of Prematurity*
- 1
- 2
- 3
- 4
General Surgery
Robotics*
- 1
- 2
- 3
- 4
Colorectal Abnormalities*
- 1
- 2
- 3
- 4
Umbilical Hernia Repair*
- 1
- 2
- 3
- 4
Inguinal Hernia Repair*
- 1
- 2
- 3
- 4
Hiatal Hernia Repair*
- 1
- 2
- 3
- 4
Nissen Fundoplication*
- 1
- 2
- 3
- 4
Pyloromyotomy*
- 1
- 2
- 3
- 4
Small bowel resection/ileostomy*
- 1
- 2
- 3
- 4
Colon Resection/colostomy*
- 1
- 2
- 3
- 4
ACE/Malone Procedure*
- 1
- 2
- 3
- 4
Gastrostomy*
- 1
- 2
- 3
- 4
Appendectomy (Laparoscopic or Open)*
- 1
- 2
- 3
- 4
Cholecystectomy (Laparoscopic or Open)*
- 1
- 2
- 3
- 4
Kasai Procedure*
- 1
- 2
- 3
- 4
Trauma*
- 1
- 2
- 3
- 4
Pectus Excavatum Repair*
- 1
- 2
- 3
- 4
Pectus Carinatum Repair*
- 1
- 2
- 3
- 4
Burns*
- 1
- 2
- 3
- 4
Wound Debridements*
- 1
- 2
- 3
- 4
ECMO*
- 1
- 2
- 3
- 4
Bariatrics*
- 1
- 2
- 3
- 4
Transplants
Heart*
- 1
- 2
- 3
- 4
Lung*
- 1
- 2
- 3
- 4
Liver*
- 1
- 2
- 3
- 4
Kidney*
- 1
- 2
- 3
- 4
Organ Procurement*
- 1
- 2
- 3
- 4
Other*
- 1
- 2
- 3
- 4
Urology/GYN
Circumcision*
- 1
- 2
- 3
- 4
Hypospadias Repair*
- 1
- 2
- 3
- 4
Orchiopexy*
- 1
- 2
- 3
- 4
Orchiectomy*
- 1
- 2
- 3
- 4
Testicular Implant*
- 1
- 2
- 3
- 4
Cystoscopy with/without intervention*
- 1
- 2
- 3
- 4
Ureteroscopy with/without intervention*
- 1
- 2
- 3
- 4
Laser Lithotripsy*
- 1
- 2
- 3
- 4
Mitrofanoff*
- 1
- 2
- 3
- 4
Cystectomy*
- 1
- 2
- 3
- 4
Pyeloplasty*
- 1
- 2
- 3
- 4
Nephrectomy/Radical Nephrectomy*
- 1
- 2
- 3
- 4
IUD Insertion*
- 1
- 2
- 3
- 4
Hysterectomy (Open or LAVH)*
- 1
- 2
- 3
- 4
Vaginal Reconstruction*
- 1
- 2
- 3
- 4
Hysteroscopy*
- 1
- 2
- 3
- 4
Neurosurgery
Anterior Cervical Fusion*
- 1
- 2
- 3
- 4
Laminectomy*
- 1
- 2
- 3
- 4
Spinal Fusion*
- 1
- 2
- 3
- 4
Release of Tethered Cord*
- 1
- 2
- 3
- 4
Chiari Decompression*
- 1
- 2
- 3
- 4
Burrholes for Subdural Hematoma*
- 1
- 2
- 3
- 4
Craniotomy*
- 1
- 2
- 3
- 4
Tumor Resection*
- 1
- 2
- 3
- 4
Meningocele Repair*
- 1
- 2
- 3
- 4
Shunt Procedures (VP/VA)*
- 1
- 2
- 3
- 4
Craniosynostosis/Cranial Remodeling*
- 1
- 2
- 3
- 4
Transphenoidal Hypophysectomy*
- 1
- 2
- 3
- 4
Please list the EMR systems you have used*
*
I attest that the information I have given is true and accurate to the best of my knowledge and that I am the individual completing this form.*
*
I hereby consent to allow CrossMed Healthcare Staffing Solutions to release these skills checklist to the client facilities.*
Name*
First Last
Email*
Phone*
TODAY'S DATE*
MM slash DD slash YYYY

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Skills Checklist

Pediatric OR Skills Checklist

Age of Patients Cared For

ENT/Plastics

Orthopedics

Eyes

General Surgery

Transplants

Urology/GYN

Neurosurgery