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Wilmer Eye Institute Johns Hopkins Hospital Weekly Orientation Evaluation Form Circulating Nurse 400 North Broadway. Baltimore, MD 21287 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 Preparation Reports to room on time, obtains daily assignment and reviews scheduled cases. Performs routine cleaning before case start and after every case. Assesses and replenishes supplies in the room. Reviews surgeon preferences to plan and organize necessary supplies, instruments, medications and equipment. Assures proper functioning of equipment. Performs and documents pre-verification process (e.g. briefing with Surgeon, acquires specialty items, ensures availability of implants, etc.). Consistently Time Stamps case for “Room Ready”. Clinical Portion: Opens sterile supplies in a timely manner and observes aseptic technique and standard precautions. Greets and identifies the patient using two identifiers. Confirms accuracy of surgical consent and correct surgical site marking per protocol. Positions patients using additional devices and padding for comfort. Demonstrates correct use of equipment per protocol (e.g. Bair Hugger, SCD and TED Stockings, ESU, Lasers, etc) and documents accordingly. Performs surgical eye prep (GSS only). Assist with surgical gowning and gloving. Consistently conducts correct “Time-out” procedure per protocol. Conducts triple check of IOL implants and documents accordingly per protocol. sc 7/18/2011 Score Comments Wilmer Eye Institute Johns Hopkins Hospital 400 North Broadway. Baltimore, MD 21287 Double checks patient allergies prior to giving medication; Verifies medication name, dosage and expiration date. Demonstrates correct procurement process and documentation of specimens. Successfully performs Immediate-use Sterilization per protocol. Recognizes breaks in sterile technique and takes corrective action. Plans activities and patient flow with OR nurse coordinator. Provides patient family feedback when needed. Provides complete hand-off report to relief. After care: Consistently conducts instrument and needle count with scrub per protocol. Demonstrates Isolation Precaution process and case cleanup per protocol. Demonstrates correct application of dressing (e.g. eye patch, pressure patch, cold pack, etc) Assists with patient transfer to PACU; Provides appropriate hand-off report. Self-Management: Demonstrates professional communication/tone and positive attitude Demonstrates ability to follow and listen to directions. Maintains and updates personal references or notes 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 downtime constructively. sc 7/18/2011 Wilmer Eye Institute Johns Hopkins Hospital 400 North Broadway. Baltimore, MD 21287 SUMMARY: __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ PERFORMANCE GOAL NEXT WEEK: __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Evaluation done on: _______________(Date) Orientee: ___________________________________ Nurse Educator: ______________________________________ Preceptor: ___________________________________ Nurse Manager: ______________________________________ sc 7/18/2011