Revised10/31/2017 Gulf Coast State College

Revised10/31/2017 Gulf Coast State College CLINICAL EVALUATION as a SECOND SCRUB

NAME______Case______DATE______EVALUATOR______

Meets Standards; Meets Expectations…………………S Standards are defined as the basic principles of aseptic & Understands Standards; Needs More Practice…..…..NI operating room care as defined by AST & AORN standards. In-serviced on standards; unacceptable practice...….U Standard operating room technique.

SECTION I: U NI S N/A Comments/Learning Needs 1. Arrives on time for case/prepared for case – Punctual and Prepared. Supplies and equipment ready prior to need. 2. Demonstrates good surgical conscience. * 3. Utilizes strict sterile technique principles. Observes sterile field at all times. * Guards sterile field assertively. Initiates action for breaks assertively 4. Maintains a quiet calm environment (Asks questions at the appropriate time). 5. Efficient and Organized. U NI S N/A Comments/Learning SURGEON COMPLETES THE FOLLOWING Needs SECTION OF EVALUATION: 1. Reacts smoothly and quickly to surgeon requests. 2. Attitude/Presence: Attentive to the case. Shows interest. Remains calm under pressure. 3. Knowledge of anatomy, procedure and/or pathology is adequate. 4. Demonstrates ability to anticipate next step of procedure. 5. Demonstrates initiative at appropriate times. “Helped the doctor”. Willing to work to facilitate the case. 6. Handles, passes, and stores sharps safely. 7. Cuts suture correctly with tips of scissors and appropriate length for type suture or directions given. 8. Follows suture smoothly with no resistance to surgeon. Keeps suture taut as appropriate to the type of stitch. 9. Utilizes suction appropriately to keep field clear and does not obstruct surgeon’s field of vision unless necessary or instructed to suction. Keeps tissues moist as appropriate to prevent desiccation. 10. Applies electrocautery to clamped bleeders as instructed correctly with no sparking. Releases clamps appropriately for “flash”. 11. Maintains retraction as instructed with appropriate force. No blanching/tissue damage noted. 12. Manipulates Camera: Keeps surgeon centralized on screen, Moves in and out smoothly, Picture clear/Defogs correctly. 13. Assists with dressing/drain/procedures as instructed. 14. Communication Skills: Responds appropriately. Asks appropriate questions pertinent to the situation. Demonstrates ability to clarify and follow directions. Grade: * items are worth 10 Points – Deduct 10 points for each stared item # S______All satisfactory =A100%; # * NI or U ______X 10 pts. Deduction Any Needs improvement: Begin at 95 and deduct 5 points for each one; # NI______X 5 Pts. Deduction Any unsatisfactory: Begin at 69%hen Deduct 5 points for each additional issue NI or U) # U______X 5 Pts. Deduction = ______Final Grade COMMENTS (Use Back of form) Revised10/31/2017 Gulf Coast State College

STRENGTHS:

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AREAS TO WORK ON:

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Comments: ______

Unsatisfactory performance is defined according to the standards of operating room technique & include but is not limited to: Unsafe patient care to include failure to label medications or administer drugs or treatments correctly; Inappropriate use of equipment; Failure to protect patient leading to injury; Break in sterile technique that is not recognized or corrected appropriately; Performing skills outside scope of practice (first assistant skills, etc.) such as suturing; Demonstrates inappropriate behaviors such as threatening patient, Making patient fearful, Providing inappropriate or incorrect information, Unstable emotional behaviors, Participation in violations of patient's rights, dignity, or discrimination in any way; Unprofessional practice including language, actions or voice inflection which may compromise rapport or working relations; Failure to follow specific rules or guidelines; Failure to seek help when needed; Performing technical actions without appropriate supervision by preceptor Leaving an assignment without properly advising appropriate personnel; No show/no call-in or failure to respond to call within designated time limits.

Reviewed with Student: Date______Student Signature______Instructor Signature______