ࡱ> e "bjbjJJ 7(_b(_be>  8lJ9pf9h9h9h9h9h9h9$W; >999}'}'}'f9}'f9}'}'v57`DvB6R9909\6>>477>78}'99!9> B X:  III. List Case/Procedure experienced this week then have preceptor validate each case &record role (10%): DateCase CompletedSurgeonSiteRole 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 Completed1st2nd 3rd 4th 5th 6th 7th Specialty CompletedDutiesYesNoN/AYesNoN/AYesNoN/AYesNoN/AYesNoN/AYesNoN/AYesNoN/AVerified supplies & equipment needed for Case.Scrubbed, gowned, and gloved correctly.Setup the sterile table with instruments, supplies, equipment & medication/solutions.Performed appropriate counts with circulator prior to the case & before the incision is closed.Passed instruments & supplies to the sterile surgical team members during procedureMaintained the highest standard of sterile technique during the procedure; monitored setup.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)YesNoNIYesNoNIYesNoNIYesNoNIYesNoNIYesNoNIYesNoNIPerforms 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 observeCirculator or observeCirculator or observeCirculator or observeCirculator or observeCirculator or observeCirculator or observeSecond 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 <72nd assist, Vag. or Endo Case, completed <72nd assist, Vag. or Endo Case, completed <72nd assist, Vag. or Endo Case, completed <72nd assist, Vag. or Endo Case, completed <72nd assist, Vag. or Endo Case, completed <72nd assist, Vag. or Endo Case, completed <7First Scrub Role Completed 1-7 points of care. Met 1-7Met 1-7Met 1-7Met 1-7Met 1-7Met 1-7Met 1-7Signature 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 Clinical Scrub Journal From Date________________ to_______________ # Scrubbed __________# Circulated____ Observed_____ Name_______________________ I. Student completes - Self Evaluation (10%): A. Self-Evaluation Rating scale: Meets Standards/Shows Initiative 5 Standards are defined as The Basic Principles Meets Standards/ Meets Expectations 4 of Aseptic and Operating Room Care as defined by Understands Standards; Needs More Practice 3 AORN Standards, Standard Operating Room Technique. States Standards; Unacceptable Practice 2 Inserviced on Standards; Unacceptable Practice 1 1 2 3 4 5 N/A COMMENTS Prepared Reviewed case prior to scrub and setup. Punctual (On time/Responds smoothly to requests) Demonstrated aseptic technique/principles correctly Completes case role correctly with minimal assistance.Anticipated next step in procedure (clamp/clamp; cut; tie)Communicated w/preceptor/charge whereabouts/role/needsOpportunity 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: 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) 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 Provided Feedback regarding Expectations & performance effectively2. 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.     Reviewed 2/2017 Student Signature ____________________________ Time In: _________ Time Out: ________ Call In ______ Out______ Instructor Signature __________________________ Date due _________ Date Submitted____________ GRADE_____________  DATE \@ "M/d/yyyy" 8/25/2022 Total Clinical Hours completed this week Normal Hrs. ______ Makeup Hrs. ______Call Hrs._______ Total Hrs for semester_________ Please Note: Of the СƵ required 140 Cases: 20/30 general cases and 60/90 specialty cases are required as 1st scrub. 20 general cases and 10 cases in each of 4 different specialty cases are required in the 1st scrub roles (60 Total). 10 more cases General in either role, 20 more 1st scrub cases and the last 50 cases in either role can be obtained in any type of case. 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