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Skills and Procedures Form - Orthopedic Surgery
General Orthopedic
Surgical
Nonsurgical
Application of casts, specify
Plaster
Other
Procedures
Please list the approximate number performed within the past 24 months
Pediatrics
Hand
Sports / rehabilitative
Diagnostic arthroscopy
Operative arthroscopy
Knee
Ankle
Shoulder
Other
Amputation
Reimplantation
Total joints
Knee
Shoulder
Hip
Ankle
Other
Tendon repair
Skin grafts
Spinal surgery
Cervical
Lumbar
Halo device
Application
Management
Harrington instrumentation
Percutaneous discectomy
Chemonucleolysis
Peripheral nerve disorders
Myelogram
Arthrogram
General trauma
Ventilator management
Other
Do you feel comfortable supervising CRNA’s?
Yes
No
How long has it been since you last supervised a CRNA?
Please list any limitations or comments on information provided above:
I affirm that all information provided on this page is true and accurate.
*
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Date
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