Reviewed 2/2017

III. List Case/Procedure experienced this weekthen have preceptor validate each case record role(10%):

Date / Case Completed / Surgeon / Site / Role Performed (1st Scrub, 2nd Scrub/2nd Assist, or Observe/Circ Role)

IV. Other Experiences/ Skills completed (Prep; Catheter insertion; etc.) (5%):______Scrub Role Definitions:

The student surgical technologist performed the following duties during each surgical intervention, with proficiency:

Number from above/Case Completed / 1st / 2nd / 3rd / 4th / 5th / 6th / 7th
Specialty Completed
Duties / Yes / No / N/A / Yes / No / N/A / Yes / No / N/A / Yes / No / N/A / Yes / No / N/A / Yes / No / N/A / Yes / No / N/A
  1. Verified supplies equipment needed for Case.

  1. Scrubbed, gowned, and gloved correctly.

  1. Setup the sterile table with instruments, supplies, equipment & medication/solutions.

  1. Performed appropriate counts with circulator prior to the case & before the incision is closed.

  1. Passed instruments supplies to the sterile surgical team members during procedure

  1. Maintained the highest standard of sterile technique during the procedure; monitored setup.

  1. Maintain Sterile Technique: recognized breaks in technique demonstrated knowledge of how to correct with appropriate technique.

Performance Satisfactory - Circle Yes, No, or NI (If No/NI – Choose areas below needing improvement) / Yes / No / NI / Yes / No / NI / Yes / No / NI / Yes / No / NI / Yes / No / NI / Yes / No / NI / Yes / No / NI
Performs any role that does not meet the criteria for first or second scrub role including Assistant circulator, or not scrubbed in. Cases counted, but not toward the req. min. 140. / Circulator or observe / Circulator or observe / Circulator or observe / Circulator or observe / Circulator or observe / Circulator or observe / Circulator or observe
Second Scrub Role – Completed less than the 7 points of care or second assisted sponging/suctioning/cutting suture/ holding retractors/ manipulating camera, Endo cases, Vag. delivery cases. Max 10 Gen& 30 Other Spec. / 2nd assist, Vag. or Endo Case, completed <7 / 2nd assist, Vag. or Endo Case, completed <7 / 2nd assist, Vag. or Endo Case, completed <7 / 2nd assist, Vag. or Endo Case, completed <7 / 2nd assist, Vag. or Endo Case, completed <7 / 2nd assist, Vag. or Endo Case, completed <7 / 2nd assist, Vag. or Endo Case, completed <7
First Scrub Role – Completed 1-7 points of care. / Met 1-7 / Met 1-7 / Met 1-7 / Met 1-7 / Met 1-7 / Met 1-7 / Met 1-7
Signature of Preceptor/validated by:

Instructions: If student completed the entire item – check=Yes; If they completed over 50% of an item write in P for Partial. If they completed none of the item, check NO. If the item does not apply (not done for this procedure) check N/A.

IF PERFORMANCE IS NOT SATISFACTORY – NO or NI above: CHECK area(s) needing improvement:

Sterile Technique regarding ______Professional behavior regarding______

Being on time _____ Mayo setup ____Speed _____ Handling of Sharps ____Draping with______

Anticipation of routine sequences______Checking case with Preference Card ______

Knowledge of ______Procedure or Instrument(s) ______

Skills at:(load NH, Gown/glove, reload staples, assemble inst., etc.) ______

Comments:

ST Weekly ClinicalScrub Journal
From Date______to______
# Scrubbed ______# Circulated____ Observed_____ Name______

I. Student completes - Self Evaluation(10%):

A. Self-Evaluation Rating scale:

Meets Standards/Shows Initiative5 Standards are defined as The Basic Principles

Meets Standards/ Meets Expectations4 of Aseptic and Operating Room Care as defined by

Understands Standards; Needs More Practice3 AORN Standards, Standard Operating Room Technique.

States Standards; Unacceptable Practice2

Inserviced on Standards; Unacceptable Practice1 1 2 3 4 5 N/A COMMENTS

  1. Prepared– Reviewed case prior to scrub and setup.

  1. Punctual (On time/Responds smoothly to requests)

  1. Demonstrated aseptic technique/principles correctly

  1. Completes case role correctly with minimal assistance.

  1. Anticipated next step in procedure (clamp/clamp; cut; tie)

  1. Communicated w/preceptor/charge whereabouts/role/needs

  1. Opportunity for Improvement: What could I improve? and How can I improve it?(Knowledge? Performance? Skills better or quicker? Preparation?) (Plan to correct it? How to fix it? -Practice? Review? Ask? Research?) (30%):

What:

How:

  1. Strengths Identified: (I felt confident about….What did I do right/do well this week?) (20%):

D. Journal: How do I feel about this week? (20%)

1. What did I like least about this week? Why? (5)

2. What did I like best about this week? Why? (5)

  1. What break in technique or event did I witness or do this week that could have adversely affected the patient or case? What principle did it break? What did I learn by observing that? (10 Pts)
II. Evaluation of Assigned Preceptor (5%)(Name) ______@Facility ______

1 2 3 4 5 N/A COMMENTS

  1. Provided Feedback regarding Expectations & performance effectively

2. Demonstrated skills effectively that I needed assistance with.
3. Preceptor was readily avail and willing to work with me - teamwork.
4. I feel that the clinical objectives of experience are being met.
5. I would recommend this program of Surgical Technology.
PHYSICIAN: Facilitated learning experience in a professional manner.

Student Signature ______Time In: ______Time Out: ______Call In ______Out______

Instructor Signature ______Date due ______Date Submitted______GRADE______

12/3/2018Total Clinical Hours completed this week – Normal Hrs. ______Makeup Hrs. ______Call Hrs.______Total Hrs for semester______