Skill Assessment 12-1B
Name
SKILL
Instructions:
Supplies:
Donning Gown per Self (Self Gown)
Instructor will demonstrate skill. Practice skill set with your partner. When ready notify instructor to
schedule Check off. Skills assessment must be completed satisfactorily by ________________. (Due Date)
 Gown pack (gown with towel wrapped envelop style)
 Scrubs
 Sterile Gloves (Appropriate size for student)
 Mask
 Scrub Brush with nail pick and antiseptic or antiseptic and nail pick
 eyewear
Note: Student must perform skill independently without prompting.
Practice with
Partner-Date:
Step
Procedural
Steps:
1. Enter OR after surgical scrub with hands higher
than elbows; away from the face and above the
waist.
2. Front of scrubs or sleeves are not wet (states if wet
could cause strike through).
3. Secures towel: pinches in middle does not drip onto
sterile field.
4. Opens towel and positions for drying.
5. Bends at waist and dries first hand and arm without
contaminating end of towel on front of scrubs.
6. Transfer towel to opposite hand.
7. Bends at waist and dries second hand and arm
without contaminating end of towel on front of
scrubs.
8. Discards towel from appropriate height (keeps
hands above the waist – drops into garbage can)
9. Pinches gown in middle – away from neck edge.
Picks up gown and steps back.
10. Unfolds gown – being careful not to contaminate.
11. Dons gown. Inserts arms in such a manner that
hands remain in sight at all times, above the waist
and away from the face. Hands do not protrude
from end of cuffed edge. Circulator may assist by
pulling gown up onto shoulders and securing neck
edge and tying waist ties.
12. Bends forward (observes front of gown to ensure it
does not contaminate on leading edge of setup).
Secures first glove and places upside down on
gowned forearm/wrist. (thumb to thumb)
13. Pulls on glove being careful to cover stocking cuff.
14. Secures and dons second glove. Adjusts gloves to
cover stocking edge.
15. Grasps turnaround tie and passes “tabbed” string
to circulator. Turns to left and grasps the tie only
pulls tie free from tab and then proceeds to tie up.
16. Removes glove powder prn and proceeds with
case setup.
17. Prepared gown/glove setup correctly – As first
person to prepare field, did not don from the main
instrument back table ; used separate setup.
Stated rationale correctly.
Skills Testing
Date:
Comment
Correct NeedsReview
Correct NeedsReview
Correct NeedsReview
Correct NeedsReview
Correct NeedsReview
Correct NeedsReview
Correct NeedsReview
Correct NeedsReview
Correct NeedsReview
Correct NeedsReview
Correct NeedsReview
Correct NeedsReview
Correct NeedsReview
Correct NeedsReview
Correct NeedsReview
Correct NeedsReview
Correct NeedsReview
Rating
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Performance
Evaluation
Criteria
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Assembled all necessary supplies and equipment for skill testing. Arranges furniture for limited traffic.
Demonstrated correct opening of sterile gown/glove setup. Height appropriate for student. Positions gown
packet so leading edge covered. Opens first fold away from self, sides, then last toward self. Controls ends.
Flips gloves onto field without breaking technique. (unsterile hand does not cross over sterile field)
Demonstrated correct donning of sterile gown.
Student prepared and performed procedure independently. Correctly maintained sterile technique. Identified
any breaks in technique and corrected them appropriately.
Stated rationale for gown/glove procedure for sterile personnel. First person dons gown/glove from
separate setup other than main instrument table since an unsterile hand cannot reach over a sterile area.
________
________
________
________
Skill Assessment 12-1B
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Subsequent persons are gowned and gloved by the assisted glove technique or don gown/glove from a
separate setup.
Performed each step in appropriate sequence.
Overall Rating (Satisfactory; Must Redo; Fail):
Instructor
Comments
Student Signature
Instructor Signature
Date
Date
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