Download eval form-circulating

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:
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PERFORMANCE GOAL NEXT WEEK:
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Evaluation done on: _______________(Date)
Orientee: ___________________________________
Nurse Educator: ______________________________________
Preceptor: ___________________________________ Nurse Manager: ______________________________________
sc 7/18/2011