Maxim Physician Resources
Thoracic and Cardiovascular Surgery
Skills Checklist
Enter the appropriate provider code in the blank next to the procedure. Failure to fill this
out correctly can delay the screening process.
Provider Codes
1 Fully competent to perform
2 Competent with supervision
3 Not requested due to lack of expertise
Please check all that apply to your scope of practice.
I. General Procedures
___ Outpatient General Clinical Procedures Customary to the Practice of Thoracic and
Cardiovascular Surgery
___ Inpatient General Clinical Procedures Customary to the Practice of Thoracic and
Cardiovascular Surgery
II. Specific Procedures
Endoscopy
___ Diagnostic
___ Therapeutic
___ Foreign Body Work
___ Other _____________________________________________________________
Chest Wall Surgery
___ Collapse Procedures
___ Reconstructive Procedures
___ Other _______________________________________________________________
Pulmonary Surgery
___ Total and Subtotal Resection
___ Pleural Procedures
___ Other ______________________________________________________________
Esophageal Surgery
___ Reconstructive
___ Excisional
___ Manipulation and Dilation
___ Other ______________________________________________________________
Diaphragmatic Surgery
___ Diagphragmatic
___ Other __________________________________________________________
Vascular Surgery
___ Aortic Excisional, Replacement and Reconstrcution
___ Peripheral Arterial Recontstructional Work
___ Aortography
___ Angiocardiography
___ Aortic and Pulmonary Vascular Reconstruction for Congenital Defects
___ Other ____________________________________________________________
Cardiac Surgery
___ Without Cardiopulmonary Bypass
___ With Cardiopulmonary Bypass
___ Other ______________________________________________________________
Procedures Not Listed Above
___ Heart Transplant
___ Lung Transplant
___ Thoracoscopy
___ Conscious Sedation
___ Other_______________________________________________________________
Printed Name: ________________________________________________________________
Signature: _________________________________________________ Date: ____________