Surgery, RN First Assist

NAME: ______________________________________________________ DATE: __________
Please cross off any privilege that is NOT requested
1. Assist with the positioning, prepping and draping of the patient or perform these independently if so
directly by the surgeon.
2. Provide Retraction by:
a. Closely observing the operative field at all times.
b. Demonstrating stamina for sustained retraction.
c. Retaining manually controlled retractors in the position set by the surgeon with regard to
surrounding tissue.
d. Managing all instruments in the operative field to prevent obstruction of the surgeon’s view.
e. Anticipating retraction needs with knowledge of the surgeon’s preferences and anatomical
3. Provide Hemostasis by:
a. Applying electrocautery tip to clamps or tissue in a safe and knowledgeable manner as directed
by the surgeon.
b. Sponging and utilizing pressure as needed.
c. Utilizing suctioning techniques.
d. Applying clamps on vessels and the tying or electrocoagulation of them as directed by the
e. Placing suture ligatures in tissue as directed by the surgeon.
f. Placing hemoclips on vessels as directed by the surgeon.
4. Perform Knot Tying by:
a. Having knowledge of the basic techniques.
b. Tying knots firmly to prevent slipping.
c. Avoid undue friction to prevent fraying of the suture.
d. Carrying the knot down to the tissue with the tip of the finger and laying the strands flat.
e. Approximating tissue rather than pulling tightly to prevent tissue necrosis.
5. Provide Closure of Layers by:
a. Correctly approximating the layers under the direction of the surgeon.
b. Demonstrating knowledge of different types of closure.
c. Correctly approximating skin edges utilizing skin staples.
NAME: ______________________________________________________ DATE: __________
6. Assist the Surgeon at the completion of the Procedure by:
a. Affixing and stabilizing all drains.
b. Cleaning the wound and applying the dressing.
c. Assist with applying casts, splints, and various other immobilization devices.
I have requested only those privileges for which by education, training, current experience and demonstrated
performance I am qualified to perform, and that I wish to exercise at HealthAlliance facilities. I also request the
ability to do any procedure in an emergency situation.
Applicant’s Signature: ________________________________________ Date: ________________
As part of the appointment / reappointment process, I, as Chairman of the Department, have reviewed this
physician’s privileges and recommend continuation of these privileges and the additions noted.
Department Chair’s Signature: ___________________________________Date: ________________
Broadway and Mary’s Avenue Campuses