/depts/,/depts/uwhealth/,/depts/uwhealth/ambulatory-education/,/depts/uwhealth/ambulatory-education/ambulatory-orientation/,/depts/uwhealth/ambulatory-education/ambulatory-orientation/checklists/,/depts/uwhealth/ambulatory-education/ambulatory-orientation/checklists/resources/,

/depts/uwhealth/ambulatory-education/ambulatory-orientation/checklists/resources/GeneralSurgery.pdf

20170367

page

100

UWMF,

Learning and Development,

Departments & Programs,UW Health,Ambulatory Education,Ambulatory Orientation,Checklists - Core and Department Specific,Resources

General Surgery

General Surgery - Departments & Programs, UW Health, Ambulatory Education, Ambulatory Orientation, Checklists - Core and Department Specific, Resources


1

GENERAL SURGERY CLINICAL TRAINING CHECKLIST ----- This is due three months from hire date------

Employee Name: __________________________________ Employee Credentials:________ Hire Date: ____________

Clinic Location/ number: _______________________ Employee Number ________________________

*** N/A on checklist indicates that it is not indicated for the employee***
*Refer to appropriate UWMF policy ***Each area should either be discussed or observed by preceptor***

AREA OF ORIENTATION Discussed Observed Preceptor’s Signature Completed date
Employee is able to gather data relevant to the following:
Signs and symptoms of Breast Disease
Pre-operative evaluation
Post operative assessment
Signs and symptoms of Colon Cancer
Pre-operative evaluation
Post operative assessment
Signs and symptoms of Rectal Fissure/Fistula
Pre-operative evaluation
Post operative assessment
Signs and symptoms of Hemorrhoid/Thrombosed Hemorrhoid
Pre-operative evaluation
Post operative assessment
Signs and symptoms of Acute Abdomen
Pre-operative evaluation
Post operative assessment
Signs and symptoms of Peripheral Vascular Disease
Pre-operative evaluation
Post operative assessment
Signs and symptoms of Varicose Veins/Spider Veins
Pre-operative evaluation
Post operative assessment
Signs and symptoms of Peri-Rectal Abscess
Pre-operative evaluation
Post operative assessment



2
AREA OF ORIENTATION Discussed Observed Preceptor’s Signature Completed date
Employee is able to gather data relevant to the following:
Signs and symptoms of Diverticulitis Diverticulosis
Pre-operative evaluation
Post operative assessment
Signs and symptoms of Gall Bladder Disease
Pre-operative evaluation
Post operative assessment
Signs and symptoms of Hernia
Pre-operative evaluation
Post operative assessment
Signs and symptoms of Thyroid/ Parathyroid
Pre-operative evaluation
Post operative assessment
Signs and symptoms of Pilonidal Cyst
Pre-operative evaluation
Post operative assessment
Signs and symptoms of Reflux / GERD
Pre-operative evaluation
Post operative assessment
Signs and symptoms of
Pre-operative evaluation
Post operative assessment-Call Backs

Patient Education- Employee participates in patient/family teaching
Breast diagnosis*
Signs and symptoms incarcerated hernia
Post op complications
Wound care*
Unna boot care*
Drain care
Pre op teaching related to specific surgery
Varicose vein prevention
Gallbladder diet
Bowel Prep *





3
AREA OF ORIENTATION Discussed Observed Preceptor’s Signature Completed date
Able to elicit patient’s expectations in medical care
Able to determine patient’s knowledge level/deficit and ability to understand
Able to identify cultural practices related to care
Able to elicits info regarding relationships with significant others
Complies with HIPAA regulations

Employee is able to appropriately care for a patient with the following:
JP Drains
Unna Boot *
Colostomy and Ileostmy
AV Shunt/Fistula
Port-a-cath
Wound Packing
Sutures Staples*

Proper and complete labeling of specimens and paperwork (in needed)

Employee is able to demonstrate competence regarding the following
surgical-related items

Schedule and Pre-authorizations
Surgical agreements and Pre-Op packets
Labs, Chest X-rays, EKG, other Pre-op Testing

Employee is able to demonstrate ability to consults/referrals to other
departments

i.e.: Plastics, Dermatology, Nutrition, Oncology

Counseling- demonstrate competence in counseling and provide appropriate
resources

Reach for Recovery
Women's Health Center
I Can Cope

Employee is able to demonstrate ability regarding Equipment and Supplies
Assure all equipment/supplies are available based on patient needs
Assure all equipment functions before use
Assure all emergency equipment/supplies are current and available at all times
Demonstrate competence in the care of sigmoidoscopy equipment
Assure that Instrument trays, Anoscope, Ultrasound are set up correctly


4
AREA OF ORIENTATION Discussed Observed Preceptor’s Signature Completed date
Procedures- Demonstrate competence to assist/patient care/follow-up
set-up and clean up

Breast biopsy and Needle localization *
Lipoma, Sebaceous Cyst, Skin Lesions*
Temporal artery biopsy*
Hemorrhoid Banding, Lance Thrombosis*
Flex sig; Proctoscopy vs Anoscopy *
Bowel prep and instructions*
Vein injection and Ligation *
Inserts Foley catheters *

Procedures- Demonstrate competence to set-up and clean up
Breast biopsy and Needle localization *
Lipoma, Sebaceous Cyst, Skin Lesions*
Temporal artery biopsy *
Hemorrhoid Banding, Lance Thrombosis*
Flex sig; Proctoscopy vs Anoscopy*
Bowel prep and instructions *
Vein injection and Ligation *
Inserts Foley catheters *

Proper and complete labeling of specimens and paperwork (in needed)

Diagnostic/therapeutic tests- Demonstrate competence to assist/set-
up/patient care/follow-up

Breast Ultrasound
Breast Lump and Thyroid needle aspiration
Breast core needle biopsy
Cultures
Specimens

Employee is able to demonstrate ability in Sterilization of
Instruments/Autoclaving

Assures instrument cleaning is properly completed
Assures proper wrapping and marking of packs
Proper cleaning of sigmoidoscope and anoscope
Assures packs are sterile when returned from autoclaving



5
AREA OF ORIENTATION Discussed Observed Preceptor’s Signature Completed date
Administration of Medication
Understands the following drug compatibility’s
Verbalize appropriate dose, mechanism, side effects of the following
medications:

Lidocaine 1% with and without epinephrine
Lidocaine 2% jelly
Nitroglycerine.2% in petrolatum
Meperidine
Midazolam
Vicodin/Hydrocodone
Percodet/Percodan
Sodium Morrhuate
1% Silver Sulfadiazine Cream
Silver Nitate
Ethyl Chloride
Ibuprofen
OTC stool softeners
Go-Lytely
Diltiazem Crème 2%/ 30 gm bottle

Prepare and dispenses medications per protocol
Administer IM, SQ adult, ID, and sublingual medications*

Controlled Substances Abuse *
Properly documents administered medications*
Properly disposes of expired medications*
Properly disposes of unused or discarded or refused medications*

General Surgery Policies
Post Operative call backs
Triage calls
Documentation of patient phone calls


Obtains vital signs* (Wt, Ht, BP, P, & Pulse ox), smoking history
Oxygen delivery and pulse ox




6
Status/Recommendations/Comments:
____________________________________________________________________________________________________________________

I, _________________________________________ (employee name) have completed the General Surgery Clinical Training Checklist and attest
the information is true and valid. I have demonstrated or discussed these skills and I am responsible for performing patient care as a Certified
Medical Assistant / Licensed Practical Nurse / Registered Nurse (circle one).

__________________________________________________ ___________________
Preceptor Date

____________________________________________________ ___________________
Supervisor Date

__________________________________________________ ___________________
Provider Date

Additional Preceptor Signatures/initials:
1. _________________________________________________
2. _________________________________________________
3. _________________________________________________
4. _________________________________________________

Initially Completely 6-13-02, updated 6-27-03, 08-26-04, 09-29-04, 03-04-05, 8-3-05, 07-30-07, 9-10-11, 3-14-2012, 6-20-2014, 3-1-2017

 Send the original signed Clinical Training Checklist to Clinical Staff Education - 1035.
 One copy of the signed Clinical Training Checklist should be placed in the clinic’s staff employee’s file, and a copy given to the employee.

REFERENCES:
Brener, T., Doyle, R.M. (Ed.). (2008). Nursing 2008 drug handbook. Philadelphia, PA: Lippincott Williams & Wilkins.
Perry, A.G. & Potter, P.A. (2002). Clinical nursing skills & techniques. (5th ed.). St. Louis, MO: Mosby.
Perry, A.G. & Potter, P.A. (2009). Fundamentals of nursing. (7th ed.). Hall, A. & Stockert, P.A. (Eds.). St. Louis, MO: Mosby Elsevier.