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Student:~

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Clinical Facility~~~

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Date:

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Gateway Technical College Surgical Technology Program

Clinical Evaluation
512-133 Clinical 2
Scoring for Clinical Evaluation 4 = Excellent 3.5 = Very Good 2.5 = Average 2 = Acceptable

3 = Good o = Unacceptable [Below 2]

Professional Characteristics Competency


--.

Comments

A.A~cept Responsibility for OWn Experiences. . 1. Adheres to dress code

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.-

2.5

2 2 2

8)3.5

3 2.5

- 2. Demonstrates Dependability

Missed daysft

8
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I
3.5 312.5
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I

3. Communicates effectively

(8)3.5 3 2.5 2

4. Demonstrates professional interpersonal relationship behavior

0
..:

3.5 3 2.5

B. PerformsAssigned
'.

Duties.
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]3.5

3.5

3 2.5 .2
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1. Acknowledges the S-T's limits of individual responsibility: self, profession and employer. 2. Adheres to legal responsibilities

31 2.5 2

0)3.5

2.5

3. Takes responsibility for own behavior C. Demonstrates Employability Skills.


.

8
4.5

3.5 3

2.5

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- -

3 2.5 2 2,5 2
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D. Assesses learning value of clinical .Experiences.

{v 3.5
..

Technical Skills Evaluation

Demonstrate

basic clinical skills


Comments.

1. Checks supplies and equipment

needed for tIre surgical procedure using preference card. 2. Scrubs, gowns and gloves self fo]]owmg site routine.
3. Sets up sterile table with instruments, supplies, equipment

{V3.5

2.5

(8)3.5 3 2.5 2 0
4 3.5G 2.5 2 0

and medicatine/soluaons
for the procedure.

needed
4

4. Performs appropriate counts with

the circulator prior to the procedure and before the incision is closed.
5. Gowns and gloves team.

3'D
3

2.5

~3.5 4 3.5

2.5

2 2

0 0

6. Assists wifh draping the sterile field.


7. Passes instrements and supplies

G) 2.5

to the sterile surgical team members during the procedure.


8. Maintains the highest standard of sterile technique during the procedure. 9. Responds ~ropriately to (~3 2.5 2 0

4 3.502.5

surgeon's requests 10. Sequences surgical procedures 11. Passes sutnre safely. 12. Initiates
GOIIJIts

3.5(})

2.5 2
2

0 0 0

4(3.~ 3-- 2.5 4 ~y 3,

at needed times

2.5 2

during procedures.

13. Prepares sterile dressings.


14. Performs ternlinal activities of

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20

3 2.5 2 0

cleaning and peeparation of instruments, supplies and the OR.

Ins~\~ctO!r"':s Comments;

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Student"s Comments: -------

Evaluat~
Student's Signature:

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_____________ Date: