PERFORMANCE EVALUATION CHECKLIST
Name of Student:
Level & Block: School Year & Term: Overall rating
Area of Assignment: Inclusive Dates: ___________
SURGICAL HANDWASHING
Procedure/ Skill Performed Performed Unable to Remarks
Independentl with Perform
y Assistance
4-5 2-3 0-1
1. Remove any watches and
rings from your hands. Ensure
that your sleeves end at least
two to three inches above your
elbows. Roll your sleeves up if
necessary
2. Before beginning the
scrubbing process open your
gown and gloves using aseptic
technique and ensure they
remain.
3. Wash your hands with
regular soap to remove any
gross debris. Rinse your hands
by keeping them elevated and
let the water run down to your
elbows.
4. Remove scrub brush from
the package and use nail
cleaner to clean the fingernails.
5. Squeeze scrub brush
under water to release soap
from sponge
6. With scrub brush
perpendicular to fingers, begin
to scrub all four sides of each
finger with back-in-forth
motion.
7. Scrub dorsal and palm
surfaces of hand and wrist with
a circular motion.
8. Starting at the wrist, scrub
all four sides at the arm to the
elbow.
9. Transfer scrub brush to
the other hand and repeat
steps 6 to 8
10. Discard scrub brush and
rinse hands and arms, starting
with the fingertips and working
toward the elbows
11. Allow contaminated water
to drip off the elbows by
keeping hands above the wrist
12. Dry with the sterile towel.
Using care not to let the towel
touch anything, take the top of
the towel and pat one hand the
forearm dry. Carefully take the
bottom of the towel and pat
dry your other hand and
forearm.
Remarks:_______________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
___________________
________________________________ _______________________
Conformed: Student’s Signature Clinical instructor
PERFORMANCE EVALUATION CHECKLIST
Name of Student:
Level & Block: School Year & Term: Overall rating
Area of Assignment: Inclusive Dates: __________
GOWNING AND CLOSED GLOVING
Procedure/ Skill Performed Performed Unable to Remarks
Independentl with Perform
y Assistance
4-5 2-3 0-1
1. Before entering the
operating room or treatment
area, apply cap, face mask,
eyewear, and foot covers
(paper or cloth covers fit over
work shoes).
2. Perform thorough surgical
hand wash.
3. circulating nurse assists by
opening a sterile pack
containing sterile gown (folded
inside out).
4. Circulating nurse prepares
a glove package by peeling the
outer wrapper open while
keeping inner contents sterile.
Places inner glove package on
sterile field created by sterile
outer wrapper.
5. Reach down to sterile gown
package; lift folded gown
directly upward and step back
away from table.
6. Holding folded gown,
locate neckband. With both
hands grasp inside front of
gown just below neckband.
7. Allow gown to unfold,
keeping inside of gown toward
body. Do not touch outside of
gown with bare hands.
8. With hands at shoulder
level, slip both arms into
armholes simultaneously (see
illustration). Ask circulating
nurse to bring gown over your
shoulders by reaching inside to
arm seams and pulling gown
on, leaving sleeves covering
hands.
9. Have circulating nurse
securely tie back of gown at
neck and waist (see
illustration). (If gown is
wraparound style, do not touch
sterile flap to cover it until you
are gloved.)
10. Closed gloving
a. With hands covered by
gown sleeves, open inner
sterile glove package.
b. With dominant hand
inside gown cuff, pick up glove
for non- dominant hand by
grasping folded cuff.
c. Extend non- dominant
forearm with palm up and
place palm of glove against
palm of non- dominant hand.
Glove fingers point toward
elbow.
d. Grasp back of glove cuff
with covered dominant hand
and turn glove cuff over end of
non-dominant hand and gown
cuff
e. Grasp top of glove and
underlying gown sleeve with
covered dominant hand.
Carefully extend fingers into
glove, being sure that glove
cuff covers gown cuff
f. Glove dominant hand in
same manner, reversing hands
(see illustration). Use gloved
non- dominant hand to pull on
glove. Keep hand inside sleeve
(see illustration)
g. Be sure that fingers are
fully extended into both gloves.
11. For wrap around sterile
gowns: take gloved hand and
release fastener or ties in front
of gown.
12. Hand paper tab connected
to sterile tie to circulating
nurse, who is non-sterile (see
illustration). Circulating nurse
stands still as you turn
completely around to left,
allowing for margin of safety as
gown wraps around and covers
your back. Take back sterile tie
from circulating nurse and
secure tie to gown.
Remarks:_______________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
___________________
________________________________ _______________________
Conformed: Student’s Signature Clinical instructor
