ࡱ> e =bjbjJJ 0(_b(_b !TT84H$[6plllll7!7!7!5555555$7:67! @7!7!7!6TTll6k0k0k07!vTRll5k07!5k0k0b4|"&5l1 !j45+60[646%;"*%;$&5%;&57!7!k07!7!7!7!7!66A)*7!7!7![67!7!7!7!%;7!7!7!7!7!7!7!7!7!B : Gulf Coast State College STUDENT ASSISTANT CIRCULATOR EVALUATION FORM Name_________________________________Date______________Evaluator____________________ Minimum Acceptable Score score 95 with a Maximum of 124. *Critical items must achieve a 4 2 Satisfactory forms required for Graduation. Meets Standards/ Meets Expectations 4 Standards are defined as The Basic Principles Understands Standards; Needs More Practice 3 of Aseptic and Operating Room Care as defined by AST and States Standards; Unacceptable Practice 2 AOR N Standards. Standard Operating Room Technique. Inserviced on Standards; Unacceptable Practice 1 1 2 3 4 N/A Pts. Comments/Identified Learning Need Arrives on time/Attired correctly.*Wipes down room/Ensures equip there/ Checks suction is working.O.R. table: Sets up/ensures draw sheet , armboards on one side& operates correctly.Gathers/checks sterile supplies using preference card correctly.Open sterile supplies correctly.Assists with Initial Counts and medications correctly.Observes circulator who Checks Chart (Consent form/preop checklist) Identifies Patient, allergies, NPO status, surgical site correctly. Interacts with patient appropriately.Assists patient transfer on & off OR table; applies safety strap correctly.*Provides comfort/safety measures, warm blanket, cares for dentures, etc. Assists with induction as directed. Maintains Quiet Room. Assists with Positioning using equip/safety measures correctly.Assists with and applies ESU grounding pad as directed correctly.Operates O.R. lights (Ensures dialed to lowest level then turns on or off).Open glove technique correctly.Assists with skin prep correctly for procedure; ensures check-allergies prior.Assists with Catherization of patient as permitted by facilityTies gowns correctly.Assists with draping without contaminating.Position/Connects suction correctl .Positions/Connects ESU (Bovie) correctly; states settings out loud when turning unit on.Participates in Pause for the Cause or Time out correctly. Pour solutions correctlyAssists with intraop and closing counts appropriately (adds items to counts when opening as directed by team, sorts into visible devices) )Attentive to surgery, provides additional supplies. Takes initiative &/or asks to help. Communicates appropriately during surgical procedure. Assists with family contact appropriately as and when directed. Observes/Assists with documentation as per policy and directed by staffObserves/Assists with specimen care correctly Assists with Securing dressingsAssists with Transport to PACU/ICUAssists with Room Turnover postopPrepares Room for next patient Total Points (Add each column straight down; then add across for Total Sum) Next Divide Total Points earned by Total Possible Points for Final Grade. (Grade: 90-100%A; 80-89 B; 70-79% C; Below 70 unacceptable) = _______points/Total Possible Points ________= _____Grade Based on a 4 points/item = 124 pts possible (Deduct 4 points for each N/A; Adjusted Total Points possible = __________)Strengths identified: Suggestions for improvement:  Unsatisfactory performance is defined according to the standards of operating room technique & include but is not limited to: Unsafe patient care to include failure to label medications or administer drugs or treatments correctly; inappropriate use of equipment; failure to protect patient leading to injury; break in sterile technique that is not recognized or corrected appropriately; Performing skills outside scope of practice (first assistant skills, etc.) such as suturing; Demonstrates inappropriate behaviors such as threatening patient, making patient fearful, providing inappropriate or incorrect information, unstable emotional behaviors, participation in violations of patient's rights, dignity, or discrimination in any way; unprofessional practice including language, actions or voice inflection which may compromise rapport or working relations; Failure to follow specific rules or guidelines; Failure to seek help when needed; performing technical actions without appropriate supervision by preceptor Leaving an assignment without properly advising appropriate personnel; No show/no call-in or failure to respond to call within designated time limits.      Revised 10/31/2017 Reviewed with Student: Date______________________ Student Signature_________________________________________________ Title of person Evaluating_________________________ Evaluator Signature_______________________________________________ Additional room for Student evaluation or comments when needed: Comments: Strengths: Suggestions for Improvement: Reviewed with Student: Date______________________ Student Signature_______________________________ Instructor Signature_______________________________ !*35HOm|~( + / 1 2 U W \   ! 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