CSCollege of Southern Idaho
SURGICAL TECHNOLOGY PROGRAM
CLINICAL EVALUATION
Key:
Students Name: _____________________________________ Date: ________
Clinical Site: ____________________________________________________
Case Scrubbed:________________________________Preceptor _____________
Attitude and Motivation
1.
Was the student prepared for the procedure?
(To help open & check the case cart?)
2.
Did the student check the doctor’s preference card?
3.
Was the student attentive during the procedure?
4.
Did the student accept and profit from constructive criticism?
5.
Did the student wear safety glasses during each procedure
S = Satisfactory
U = Un-Satisfactory
B = Beginning Skill
NA = Not Observed
S
___
U
___
B
___
NA
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Comments: ____________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
Aseptic Technique
S
U
B
NA
1.
Did the student gown and glove self-using the correct method?
___ ___ ___ ___
2.
Did the student recognize breaks in sterile technique?
___ ___ ___ ___
3.
What were they? _______________________________
4.
Did the student know how to correct breaks in sterile technique? ___ ___ ___ ___
5.
What did the student do? __________________________
6.
Did the student gown and glove the doctor?
___ ___ ___ ___
7.
Did the student help or initiate draping?
___ ___ ___ ___
Comments: ____________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
Knowledge of Instruments and Equipment
S
U
B
NA
1.
Did the student know the basic instruments?
___ ___ ___ ___
2.
Did the student pass instruments correctly?
___ ___ ___ ___
3.
Did the student keep the Mayo stand neat during procedure?
___ ___ ___
4.
Did the student handle and care for instruments correctly?
___ ___ ___ ___
5.
Did the student ask for assistance as needed or appropriate?
___ ___ ___ ___
6.
Did the student handle sutures correctly?
___ ___ ___ ___
7.
Did the student know the names and types of needles?
___ ___ ___ ___
Comments: ____________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
Patient Safety
S
U
B
NA
1.
Did the student count according to hospital policy?
___ ___ ___ ___
2.
Did the student request counts when needed?
___ ___ ___ ___
3.
Did the student identify specimens?
___ ___ ___ ___
4.
Did the student identify medications correctly?
___ ___ ___ ___
5.
What meds did the student use? ______________________________________
Comments: ____________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
Signature (please print) _______________________Date of evaluation________________
Jmilligan/revised 2008
Document suitable for E-mail from the preceptor’s address
E-mail to jmilligan@csi.edu