Skills Assessment

The skills assessment sheet, word for word. The check-off list comes first, then the grading rubric, then each skill in the order it appears on the sheet.

Grading rubric

Skills Assessment Check Off

Skills, in order

1. OR attire/PPE

Reference: Pg. 133

• The student can state the purpose of basic OR attire and identify circumstances when OR attire is required.
• The student can state the difference between restricted, semi restricted, and non-restricted areas.
• The student states that the bouffant cap should be donned before scrubs. All hair is contained in the bouffant cap.
• The student is wearing appropriate scrubs with no visible under shirts/ undergarments. The student states that a scrub jacket should be worn to prevent skin shedding when not scrubbed in. If wearing a scrub jacket it is tucked, close fitting, or buttoned/snapped.
• The student is wearing an ID badge.
• Shoes are closed toed and appropriate footwear for the OR. (no holes/no heels) Designated OR shoes are worn or shoe covers.
• All jewelry is removed or confined within surgical attire.
• A surgical mask is donned. (Conforms to nose, ties are not crossed, no venting, handled by strings, states that masks should be discarded following procedures and/or if wet or soiled.)
• Eyewear donned. Eyewear is worn during the entire procedure. Eyewear is secure. (Glasses are not acceptable eyewear, unless side shields are in use.) States if non disposable, eyewear is wiped down and if disposable it is disposed of after procedure.
• The student states that PPE is not to be worn outside of the OR department or suite and OR attire is not to be worn outside of the facility or is to be covered.

2. Basic handwash

Reference: Pg. 131

• The student can state the purpose of, and identify when a handwash should be performed.
• The student has removed all jewelry. Nails are natural, neatly trimmed, and polish free.
• The student has checked the integrity of the skin of the hands and wrists.
• The faucet was turned on and water temperature was properly adjusted.
• Hands and wrists are wet, fingertips are pointing down, soap is applied.
• Moderate friction is used to create a circular motion and fingers are interlaced to adequately clean all areas of the hands and wrists. Nails are cleaned with a nail brush, if needed.
• Hands were washed for an accurate amount of time and all surfaces were cleaned.
• Hands are rinsed from the wrist to fingertips keeping the fingertips pointing down.
• Hands are dried with a paper towel.
• Water is turned off with the paper towel and discarded appropriately.

3. Wipe down OR

Reference: Pg. 186-187

• The student is donned in appropriate OR attire and PPE including exam gloves.
• A basic handwash has been performed.
• The student demonstrated properly wiping down all OR equipment and furniture, top to bottom, beginning with the OR lights.
• Gloves/wipes are properly disposed of and a basic handwash is performed.

4. Open gloving

Reference: Pg. 145-146

• Student performs a basic handwash.
• The student gathers gloves and organizes an ergonomic workspace to create a proper sterile setup.
• The student describes when the open glove technique will be necessary.
• The student opens sterile gloves, only touching the outer edges of the inside wrapper, up to 2", creating the sterile parameters.
• The first glove is secured using a pinching technique, lifting the glove up and away from the wrapper.
• The first glove is applied correctly, without touching the glove exterior and the cuff is unfolded without touching the glove exterior.
• The second glove is retrieved using the fingertips of the gloved hand, inserting under the cuff.
• The second glove is lifted up and away from the wrapper.
• The second glove is applied correctly, without touching the glove exterior and the cuff is unfolded without touching the glove exterior.
• The student states that they must now use sterile technique.

5. Scrubbing - counted method

Reference: Pg. 137

• The student is wearing proper OR attire/PPE and has gathered all supplies. Sleeves are rolled if necessary.
• The student can define surgical scrub and the purpose.
• The student inspects the skin integrity of their hands and arms.
• The student opens the sponge/brush package.
• The student turns on the water and properly adjusts the temperature.
• The student bends at the waist to ensure they do not wet the front of their scrubs.
• The student demonstrates a basic handwash.
• The student uses a nail pick to clean under their fingernails.
• The student appropriately discards the nail pick.
• The sponge/brush is properly wet and soap is applied if not impregnated with cleansing solution.
• Fingernails are scrubbed for 30 strokes.
• All areas (other than fingernails) including between the webs of fingers are scrubbed using 20 strokes, progressing from fingers to 2" above the elbow. (If contaminated during the process of the scrub, the student scrubs again for 10 strokes).
• The hands and arms are rinsed, without contamination, and the fingertips remain above the elbows.
• The sponge/brush is disposed of in the garbage, from an appropriate height to avoid contamination.

6. Opening peel packs

Reference: Pg. 149

• The student is wearing proper OR attire and PPE.
• The student has demonstrated a basic handwash.
• The integrity of the packaging is inspected.
• If applicable, verify indicators have changed and check expiration dates.
• Maintain the proper distance from the sterile field.
• Grasp one edge of the peel pack in each hand and slowly separate the peel pack.
• Balance the item within the package to prevent contamination.
• Gently toss the item onto the sterile field, without crossing over the sterile field.
• The student can properly identify sterile parameters.

7. Opening surgical instruments: Blue wrapped

Reference: Pg. 150

• The student is wearing proper OR attire/PPE.
• The student demonstrates hand washing.
• An integrity check is performed on the blue wrap/sterile indicator tape. The indicator tape has changed.
• Furniture is positioned appropriately for opening. The blue wrapped item is held in the hand or placed on a dry surface.
• The blue wrap is opened away from the student first, then second and third flap, without crossing over the sterile field. The last flap is opened toward the student.
• The item is visibly checked for a chemical indicator.
• The sterile item is guarded.

Retrieving the sterile item

• The student has performed a surgical scrub and is donned in sterile gown/gloves.
• The student verifies the chemical indicator has changed.
• The item is removed from the blue wrapper.
• The student steps back, keeping the instrument within the sterile field, allowing the circulator to perform an integrity check on the blue wrap.
• The item is only placed on the sterile field after the integrity and indicator have been confirmed.

8. Envelope fold and square fold

Reference: Pg. 149

Envelope fold

• The student is able to state examples and purposes for envelope folds.
• The student is wearing proper OR attire and PPE.
• The item is properly prepared for sterilization and contains a visible chemical indicator.
• The appropriate size wrapper is chosen and placed on a clean dry surface.
• The wrapper is placed diagonally and the item is placed in the center of the wrapper.
• The flaps are folded in: the 1st flap covers the entire top of the item, the 2nd flap overlaps, the 3rd and 4th flaps are folded in and tabs are created.
• Excess wrapper is tucked in and a tab is created.
• The wrapper is secured with sterile indicator tape.
• The item is properly labeled.

Square fold

• The student is able to state examples and purposes for square folds.
• The student is wearing proper OR attire and PPE.
• The item is properly prepared for sterilization and contains a visible chemical indicator.
• The appropriate size wrapper is chosen and placed on a clean dry surface.
• The wrapper is placed in a square manner and the item is placed in the center of the wrapper.
• The wrapper edge nearest the student is pulled snugly against the side and over the top of the item, covering the bottom half of the item and a folded cuff is formed.
• The top section of the wrapper is pulled snugly against the opposite side of the item and pulled down toward the user folding over top of the item and a cuff is formed that overlaps the 1st cuff.
• The left side of the wrap is folded in from the edges to form a taper and pulled snugly against the left side of the item and over the pack, another cuff is formed.
• The right side of the wrap is folded in the same manner as the left, then overlapping the previous fold, forming another cuff.
• The wrapper is secured with chemical indicator tape and properly labeled.

9. Scrubbing - waterless method

Reference: Pg. 139

• The student states application time and method is determined by the facility, research, and manufacturer's application of the agent.
• The student states that facilities may require a surgical scrub prior to use of waterless scrub. The student states the definition and purpose of a surgical scrub.
• The student inspects the skin integrity of their hands and arms.
• The student demonstrates a basic handwash.
• The student uses a nail pick to clean under their fingernails.
• The student appropriately discards the nail pick.
• The student drys their hands before applying a solution.
• Applies appropriate amount of solution using friction to clean under fingernails, nail beds and creases.
• Manufacturer's guidelines are followed for solutions regarding time and technique.
• Solution is allowed to fully dry, no fanning or waving of hands arms occurs.

10. Loading blades

Reference: N/A

• The student is donned in a sterile gown and gloves.
• The appropriate blade is chosen for the appropriate knife handle.
• The no touch technique is utilized to apply the blade to the handle.
• The no touch technique is utilized to remove the blade.
• The blade is disposed of properly/placed in the sharps box.

11. Loading a needle driver

Reference: N/A

• The student is donned in a sterile gown and gloves.
• The appropriate needle holder is chosen for the needle/suture.
• The needle is loaded using the no touch technique.
• The needle is properly loaded between 1/3 and 1/2 the length of the swaged end.
• The needle is passed safely with the tip facing the surgeon's thumb side and the end of the suture is secured and remaining within the sterile field.
• The needle is passed back in a safe manner and safely secured in a neutral zone or the sharps box/needle counter.

12. Accepting medications onto the sterile field/labeling/filling Asepto

Reference: Pg. 228-230

• The student is donned in sterile OR attire.
• The student demonstrates placement of the bowl/cup/pitcher to receive the medication.
• The circulator reads the label of the medication, the student verifies what the circulator has stated.
• The student creates an appropriate label for the medication; including the name, expiration date, concentration, and quantity.
• The circulator pours the medication into the proper container without contaminating the solution, container, or student.
• The medication container is labeled.
• The Asepto syringe is properly filled and labeled.

13. Drawing up medications/reading dosage

Reference: Pg. 228-230

• The student can state the "six rights".
• The student is donned in sterile OR attire.
• Allergies are verified.
• Student requests medication. The student and circulator visually and verbally verify the correct medication.
• The student withdraws medication properly from the vial using the correct size hypodermic needle and/or draws up the medication from the sterile field. (If from a container on the sterile field the proper protocol is followed for obtaining medication onto the sterile field.)
• The syringe is properly labeled.
• The proper hypodermic needle is placed for injection.
• The student identifies the medication when passing it to the surgeon.
• The amount of medication used is correctly stated.
• The amount of medication remaining in the syringe is correctly stated.
• All sharps are handled correctly. The one handed scoop method is used for recapping the hypodermic needle.

14. Opening a Back table and basin

Reference: Pg. 149

• The student is wearing proper OR attire and PPE.
• The student demonstrates a basic handwash.
• Assembles equipment and supplies.
• Furniture is positioned properly and appropriately for opening. Items are placed on a dry surface.
• Package outer integrity and expiration date are checked for back table pack or cover.
• Remove the outer package.
• Package inner integrity is checked.
• Break or remove the seal.
• Unfold the first flap away from the student, unfold the second fold, (if accessory items remove them), reposition yourself for opening the third fold and unfold.
• Insert hands into the cuff, grasp, and extend to cover the table.
• Move to the opposite side of the table and repeat for the fourth fold.
• Protect the sterile field.
• Package outer integrity and expiration date are checked for basin.
• Remove the outer package.
• Package inner integrity is checked.
• Place basin on ring stand.
• Break or remove the seal.
• Unfold the first flap away from the student, grasp the tabs and unfold the second and third flaps laterally.
• Open the fourth flap towards the student.
• Place the ring stand in close proximity to the back table.
• Protect the sterile field.

15. Opening surgical instruments: Asceulap pan

Reference: Pg. 149-150

• The student is wearing proper OR attire/PPE.
• The student demonstrates hand washing.
• Furniture is positioned appropriately for opening. The pan is placed on a dry surface.
• Sterile indicators/locking device is checked for integrity.
• The lid is opened in a sterile manner and is not over the sterile field.
• The lid filter indicator is checked.
• The tray is visibly checked for a chemical indicator.
• The sterile tray is guarded.

Retrieving the instrument tray

• The student has performed a surgical scrub and is donned in sterile gown/gloves.
• The student verifies the chemical indicator has changed.
• The instrument tray is lifted from the pan without contaminating the tray or gown/gloves.
• The student steps back, keeping the instrument tray in the sterile field, allowing the circulator to check the pan for dryness, cleanliness, and the lid filter indicator before placing the instrument tray on the sterile field.

16. Gowning/Gloving

Reference: Pg. 141-144

Donning a gown and gloves (self)

• The student assembled all supplies and opened sterile supplies before scrubbing.
• The gown was opened without contamination; the plastic wrapper was removed, the blue wrapped gown was placed on the mayo stand, opening away from the student first, then sides, and closest to the student, without contamination. The gloves were opened onto the sterile area within the 2" sterile parameter, in an area to avoid contamination.
• The student enters the OR after the surgical scrub keeping the hands above the elbows, away from the face and body and above the waist.
• The front of the scrubs or sleeves are not wet.
• The towel is secured pinching in the middle, no dripping onto the sterile field has occurred.
• The student bends at the waist and steps back from the mayo stand and opens the towel for drying.
• The student remains bent at the waist and dries the first hand, using one end of the towel and caution not to contaminate the towel on the front of scrubs.
• The towel is transferred to the opposite hand, using the opposite end of the towel, without contaminating the towel on the front of scrubs.
• The second hand is dried in the same manner as the first.
• The towel is discarded from an appropriate height. Hands are kept above the waist and the towel is dropped into trash.
• Pinches gown in the middle, away from the neck edge. Picks up the gown and steps back.
• Unfolds gown, using caution not to contaminate.
• Dons gown, inserting arms to keep arms in sight at all times, above the waist, and away from the face. Hands do not protrude from the end of the cuffed edge. Circulator may assist by pulling the gown up onto shoulders, securing the neck edge and tying the waist ties.
• Bends forward (observes front of gown to ensure it does not contaminate on leading edge of setup). Secures first glove and places upside down on gowned forearm/wrist (thumb to thumb/fingers facing student).
• Student pulls on glove, being careful to cover the stocking cuff.
• Secures and dons glove. Adjusts gloves to cover stocking edge.
• Grasps turnaround tag with right hand to pass tag to circulator, with left hand grasps tie only, pass tag, turn to the left (circulator passes behind), tag is pulled from ties, ties are tied.
• Student keeps hands above waist and away from face to remain sterile.

17. Draping the mayo stand

Reference: N/A

• The student is donned in sterile attire.
• The student properly drapes the mayo stand without contamination.
• Towels are properly placed and tucked.
• The sterile field is guarded.

18. Passing and handling instruments

Reference: N/A

• Student is wearing a sterile gown and gloves.
• Inspecting instruments for damage and integrity was demonstrated.
• The correct instrument is identified and chosen properly.
• The instrument is passed in a safe manner, in the position of use, and to elicit the grasp reflex.
• Curves of instruments are facing in the appropriate direction.
• The instruments are handled with care and replaced to the appropriate location.

19. Preference card checked and pulled properly

Reference: N/A

• The student demonstrated reviewing the Preference card and pulled any necessary supplies, instruments, and equipment.
• No unnecessary supplies were opened and hold items remained available.

20. Gowning and gloving a teammate

Reference: Pg. 147

• The student is wearing proper sterile OR attire.
• The student has gathered or obtained the appropriate gown and gloves for the team member.
• The towel is passed to the team member without contamination.
• The gown is presented properly and in a sterile manner with hands cuffed and protected to avoid contamination.
• The sleeves of the gown are in the proper position for gloving either assisted or unassisted.
• The right glove is prepared and presented open for application. The fingers and thumbs remain out of the way to avoid contamination.
• The left glove is prepared and presented open for application. The fingers and thumbs remain out of the way to avoid contamination.
• The student demonstrated readiness to accept the gown tie tag and properly assisted with turning.
• Sterility is maintained.

21. Removal of gown and gloves

Reference: Pg. 153

Removal of gown: during a case/end of case

• During a case: Recognizes contamination of gloves/gowns.
• The students state correct steps for replacement for the situation. If outer gloves only: remove top glove and replace with sterile gloves. If gloves are pierced, both layers of gloves contaminated, or gloves and gown contaminated; replaces gown and gloves.
• Removing gown during case: Step away from the field and request a new gown/glove setup.
• Rescrub if needed.
• Gown and glove using closed gloving technique.

After end of case

• All tasks requiring a gown and gloves are completed.
• Back of the gown is unfastened (does not reach back per self; another team member unfastens or fasteners are torn.)
• Gown is grasped near the shoulders and rolled away from self, using caution to not touch outer gown to skin.
• Remove gown and place in proper receptacle.
• Remove the first glove in glove to glove fashion. Invert and turn inside out using caution not to splatter.
• Remove the second glove skin to skin (fingers of bare hand inserted between bare skin of wrist/forearm and glove.) Invert slowly to contain the first glove in the second glove.
• Touching only the inner surface of the gloves, the gloves are placed in the appropriate receptacle.
• Basic handwash performed.

22. Transferring patient/ patient prep

Reference: Pg. 315-316

Transferring to the OR table

• The student is wearing proper OR attire.
• A basic handwash has been performed. Ideally, exam gloves are worn.
• The student can state when it is safe and appropriate for a patient to perform a self transfer and when an assisted transfer is required.
• The student states how many people are needed for an assisted transfer and their roles.
• A roller board is properly prepared for transfer for an assisted transfer.
• Once in the proper position the stretcher and OR table are both locked and verified.
• A count was performed to roll and move the patient in an assisted transfer.
• Proper body mechanics were demonstrated.
• Caution was demonstrated during transfer to ensure the patients limbs remained safe and secure and IVs and catheters were secured.
• The roller board was safely removed.
• A safety strap is placed 2" above the knees, with 2 fingerbreadths between.
• Padding is placed in pressure point areas.
• If awake, the patient is checked for comfort.

Surgical skin prep

• Proper OR attire is worn.
• A basic handwash was performed.
• The student can state the different types of surgical preps and why each is chosen.
• Patient allergies have been identified.
• Supplies are gathered.
• The patient is limitedly exposed for prepping, to maintain body heat and modesty. The skin integrity is checked.
• Sterile supplies are opened appropriately.
• The student demonstrates open gloving.
• The surgical site is cleansed first, then surrounding areas.
• The student can state the difference between the sterile and unsterile areas and does not contaminate.
• The student can state if the solution needs blotting and the appropriate dry time.

Also on the sheet

These three pages have no number on the check-off list.

Peel packing Instruments

• The student is wearing proper OR attire/PPE.
• The student has performed a basic handwash.
• The student can state an example of the usage of a peel pack.
• The proper size peel pack is chosen.
• An indicator is placed visibly in the package.
• The package is properly sealed. No gaps/creases/or holes.
• The item is properly labeled.

Properly handling sharps

• Safe handling of sharps is demonstrated.
• Sharps are secured and/or confined in one area or a neutral zone is established.
• Blades and sutures are handled with no touch techniques.
• Hypodermic needles are recapped using a one handed scoop method.
• The passing of syringes with hypos, scalpels, sutures/needles and sharp instruments are demonstrated.
• Sharps are properly disposed of and the sharps box/needle counter is utilized.

Proper counts: Sponges, sharps, and instruments

• The student is donned in a sterile gown and gloves.
• The sterile set up is complete.
• The student demonstrates counting in appropriate order: sponges, sharps, and instruments.
• Visualization of the sponges, sharps, and instruments are provided to the circulator during counts.
• The count was performed accurately.
• The student can state that appropriate times to count and that first you must count at the field, then the back table, and then off the field counts are performed.
• Visualization and verification of any items counted off the field occurred.
• The sterile field was maintained throughout the entire count.