Learning and Development,

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


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


PLASTICS - 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:
Patient’s personal and family health history
Current medications, including OTC, vitamins and herbal medications
Reason for appointment
Vital signs*, height* and weight*

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

Employee is able to recognize the signs and symptoms of the following:
Post op bleeding: pain, pressure, dizziness, obvious blood thru dressings
Post op infection: Fever greater than 101, purulent drainage, pain, foul smell
Cysts: lump under skin, can increase and decrease in size, can be inflamed and
painful at times

Lipomas: soft, “spongy” mass, usually non tender, benign, slow

Melanoma: Changing moles, asymmetrical, uneven borders, uneven dark color,
diameter>6mm, may bleed easily, can be patches, plaque or nodule.

Squamous cell: Raised pink, opaque nodules or patches, often ulcerate in center,
usually on exposed skin surfaces

Basal cell carcinoma: Raised, translucent, pearly nodules, may crust, bleed, or
ulcerate, most common on face and other exposed areas

AREA OF ORIENTATION Discussed Observed Preceptor’s Signature Completed date
Patient Education- Employee participates in patient/family teaching
Employee demonstrates knowledge & can discuss with patient:
Post op complications – infection, dehiscence, pain, nausea, vomiting
Wound care – solid knowledge base of frequently used dressings
Unna boot care
Drain care – able to milk drain, empty drain, measure and do site care.
Pre op teaching related to specific surgery
Procedure for removal of lesion -with graft or flap-
Able to explain surgery and answer pt questions

Repair of pressure ulcer-with flap or graft-
Able to explain surgery and answer pt questions

Incision and suture care
Breast reduction surgery pre and post op teaching
Breast reconstruction
-with TRAM or expander - Able to explain surgery and answer pt questions

Insertion of implant after removing expander
Reconstruction after Moh’s surgery
Recovery period for each procedure and where recovery is to take place ie.
Home, hospital, or nursing home

Employee demonstrates knowledge in Consults/referrals to other departments
Dermatology, Oncology, ENT, PT, OT
Refer to specialty support groups
Obtain prior authorization for medications
Be able to refer to appropriate “other” clinics and physicians as needed

Employee demonstrates knowledge of Equipment/ 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

Procedures- Demonstrate competence to assist with or perform:
Needle localization
Set up for all in office procedures
Dressing changes to wound*
Application of UNNA boot*
Suture removal, Steri strip
Injection of local anesthesia, including proper dilution
Proper and complete labeling of specimens and paperwork (as needed)

AREA OF ORIENTATION Discussed Observed Preceptor’s Signature Completed date
Diagnostic/therapeutic tests- Demonstrate competence to assist/perform:
Follow up of medical imaging tests
Follow up of pathology reports

Employee demonstrates knowledge of Sterilization of

Assures instrument cleaning and autoclaving is properly completed
Assures proper wrapping and marking of packs
Assures proper cleaning of autoclave

Employee demonstrates knowledge related to Surgery
Schedule and Preauthorizations
Surgical agreements and Pre-Op packets
Labs, Chest X-rays, EKG*, other Pre-op Testing
Sterile setup and technique for office based surgery
Dressing surgical site at end of procedure using appropriate technique
Dressing instructions to patients prior to going home
Clinic schedule and pre-authorizations OR scheduling including pre-op and

Knowledge of what kind of surgery, where to take place, type of anesthesia and
time required for procedure

Administration of Medication
Understands the following drug compatibility’s
Verbalize appropriate dose, mechanism, side effects of the following

This list is an example, and should not be limited to the items mentioned:
Analgesics: aspirin, , ibuprofen, acetaminophen, Percocet, Vicodin
Antibiotics: amoxicillin, ceftriaxone, bacitracin ointment, penicillin,
Anti-pyretic: acetaminophen, ibuprofen,
Anesthetics: General and local
Silvadene Cream
Scar Cream: Mederma, Vitamin E cream
Administer IM adult*, SQ* adult, ID*, and sublingual* medications
Administer IV medications *
DEA Procedures/Controlled Substances Log and Controlled Substances Abuse
Understands the mixing of medications

AREA OF ORIENTATION Discussed Observed Preceptor’s Signature Completed date
Properly documents administered medications
Properly disposes of expired medications
Properly disposes of unused or discarded or refused medications

Provides URGENT Patient Care – Employee is able to:
Initiates AED (if indicted)
Appropriately care for patient requiring anti-arrhythmic medication
Initiate Chest Pain Protocol appropriately (see Emergency Procedures Manual)
Appropriately care for patient requiring anit-anginal medication
Appropriately care for patient with cardiopulmonary arrest (until advanced help

Understands and can appropriately set-up the crash cart
Stocks crash cart appropriately

Plastics Department Policies
Use of pre appointment management worksheet
Patient no show procedure
Documentation of patient phone calls
Triage of phone calls
Proper and complete labeling of specimens and paperwork (in needed)


I, _________________________________________ (employee name) have completed the Plastics 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 Completed 01-26-04 Updated 8-3-05, 8/07, 9/11, 3/12, 2/14, 6/14, 3/17

 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.

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.