Clinical Site:

1. Procedure Name: _

2. Definition of Procedure:

3. What was the purpose of the procedure:

4. What was the expected outcome of the procedure?

5. What was your role during this procedure?

6. Patient's age:

7. Patient's gender:

8. Additional pertinent patient information:

9. Discuss the relevant anatomy..

10. List the general and specific instruments that were needed for the procedure:

11. List the basic and specific supplies that were needed for the procedure:

67/n12. List the pharmaceuticals used during the procedure:

13. What type of anesthesia was used?

14. Patient position during the procedure:

15. What equipment was necessary for positioning?

16. What type of skin preparation was used?

17. Define the anatomic perimeter of the prep?

18. List the order in which the drapes were applied:

19. List any practical considerations that were taken

Why?

20. List the intraoperative procedural steps - describe the preparatory and supportive actions you had

to take during those steps:/n21. What are possible complications that may have occurred during the procedure?

22. What is the most valuable information you obtained from scrubbing this surgical procedure?

23. Comments or questions:

Student's Signature

Date