Wilmer Eye Institute
Johns Hopkins Hospital
400 North Broadway.
Baltimore, MD21287
Name : ______Specialty: ______Week: ______
Preceptor: ______Dates covered: ______
Please select the appropriate evaluation (below) for each independent function on the space provided.
1 – Supervised 2 – Assisted with coaching 3 – Independent N/A – not applicable
INDEPENDENT FUNCTION / Score / CommentsPreparation
Arrives on time. Reports to assigned room and reviews cases.
Reviews procedure from notes or preferences; Asks pertinent questions.
Prepares room by damp dusting furniture, machines, and fixtures according to policy
Confirms correct trays, instruments and supplies by using preference cards/notes prior to start of surgery; Checks with circulator for additional tasks.
Basic Aseptic Technique:
Performs correct surgical hand scrub according to AORN guidelines/policy.
Performs correct gowning and gloving according to AORN guidelines/policy.
Performs correct draping techniques (e.g. anterior segment, retina, plastics drape, etc).
Observes sterile field and takes corrective action for breaks in aseptic technique.
Clinical Portion:
Participates in time-out according to policy.
Demonstrates adherence to standard precautions and isolation precautions.
Consistently prepares back table in a timely manner.
Supplies and instruments are well organized on the back table.
Labels all drugs and solutions according to policy.
Performs “read-back” of name and dose when giving drugs or solutions to surgeons.
Perform control and final instruments and sharps counts according to policy
Performs effective and efficient instrument (e.g. forceps, blades, syringes, etc) passes.
Handles specimens carefully. Communicates name of specimen to circulator accurately.
Anticipates needs of surgeons by direct observation of surgical field or monitor.
Gives accurate hand-off to relief person (e.g. instrument and sharp counts, infusions, drugs, implants, specimens, etc)
Understands policy on routine flash sterilization. Operates sterilizers per protocol.
After care:
Efficiently breaks down surgical field.
Correctly performs instrument (e.g. forceps, probes, biom system, etc) care especially on fine and delicate instruments.
Demonstrates safe handling/disposal of sharps.
Assists with room turnover in preparation for next case.
Self-Management:
Demonstrates professional communication/ tone and positive attitude.
Demonstrates ability to follow and listen to directions.
Maintains personal references or notes and update accordingly.
Completes assignment on time
Identifies or recognizes strengths and learning needs
Independently manages stress and seeks guidance when necessary.
Demonstrates teamwork (i.e. supports team efforts)
Utilizes down time constructively
SUMMARY:______
PERFORMANCE GOAL NEXT WEEK:
______
Evaluation done on: ______(Date)
Orientee: ______Nurse Educator: ______
Preceptor: ______Nurse Manager: ______
sc 2/28/2011