Type: Individual
| Tools & Equipment | Materials |
|---|---|
| Pen | Patient Identification Wristband |
| Face Mask | Patient Surgical Consent Form |
| Hand Sanitizer | Patient Medical Record File |
| Name Badge |
| S/N | Item | Quantity |
|---|---|---|
| 1 | Patient Identification Wristband | 1 Pc per Candidate |
| 2 | Patient Surgical Consent Form | 1 Pc per Candidate |
| 3 | Patient Medical Record File | 1 Pc per Candidate |
| 4 | Pen | 1 Pc per Candidate |
| 5 | Face Mask | 1 Pc per Candidate |
| 6 | Hand Sanitizer (70% alcohol) | Enough per Candidate |
| 7 | Name Badge for Candidate | 1 Pc per Candidate |
| Items to be Evaluated | Marks Available | Marks Obtained | Comments |
|---|---|---|---|
| TASK 1: Prepare self and environment | |||
| Performed hand hygiene using hand sanitizer (Award 1 mark for proper hand hygiene or zero) | 1 | ||
| Doned face mask correctly covering nose and mouth (Award 1 mark for correct mask use or zero) | 1 | ||
| Wore name badge visibly (Award 1 mark for visible name badge or zero) | 1 | ||
| Sub-Total | 3 | ||
| TASK 2: Patient identification verification | |||
| Introduced self to patient and explained procedure (Award 1 mark for clear introduction or zero) | 1 | ||
| Checked patient wristband for full name and hospital number (Award 1 mark each for name and hospital number verification) | 2 | ||
| Asked patient to state full name and date of birth (Award 1 mark each for name and date of birth confirmation) | 2 | ||
| Cross-checked patient details on surgical consent form with wristband and medical record (Award 1 mark each for confirming name, procedure, and date on consent form) | 3 | ||
| Confirmed surgical procedure and site with patient and consent form (Award 1 mark each for procedure and site confirmation) | 2 | ||
| Documented verification details on patient record or checklist (Award 2 marks for complete and accurate documentation) | 2 | ||
| Sub-Total | 12 | ||
| TASK 3: Final patient verification before transfer | |||
| Ensured patient is positioned safely and comfortably (Award 1 mark for safe positioning or zero) | 1 | ||
| Instructed assistant to prepare for patient transfer (Award 1 mark for clear instruction or zero) | 1 | ||
| Reconfirmed patient identity and procedure with assistant (Award 1 mark for effective communication or zero) | 1 | ||
| Sub-Total | 3 | ||
| PRODUCT CHECKLIST | |||
| Patient identity verified correctly using wristband, verbal confirmation, and consent form (Award 5 marks for complete and accurate verification or zero) | 5 | ||
| Surgical procedure and site confirmed correctly and documented (Award 5 marks for correct confirmation and documentation or zero) | 5 | ||
| Sub-Total | 10 | ||
| GRAND TOTAL | 28 | ||
Type: Individual
| Tools & Equipment | Materials |
|---|---|
| Face mask | Antiseptic solution (povidone iodine 10%) |
| Headcap | Soap liquid hand wash |
| Sterile gloves | Plain paper |
| Utility gloves | |
| Mackintosh apron | |
| Surgical mask | |
| Goggles | |
| Sterile cotton swabs | |
| Sterile gauze swabs | |
| Sterile towel | |
| Running water tap with sink | |
| Pen |
| S/N | Item | Quantity |
|---|---|---|
| 1 | Face mask | 1 Pc per Candidate |
| 2 | Headcap | 1 Pc per Candidate |
| 3 | Sterile gloves | 1 Pair per Candidate |
| 4 | Utility gloves | 1 Pair per Candidate |
| 5 | Mackintosh apron | 1 Pc per Candidate |
| 6 | Surgical mask | 1 Pc per Candidate |
| 7 | Goggles | 1 Pair per Candidate |
| 8 | Sterile cotton swabs | 10 Pcs per Candidate |
| 9 | Antiseptic solution (povidone iodine 10%) | 100 ml per Candidate |
| 10 | Sterile gauze swabs | 5 Pcs per Candidate |
| 11 | Sterile towel | 1 Pc per Candidate |
| 12 | Running water tap with sink | 1 per Candidate |
| 13 | Soap liquid hand wash | Enough per Candidate |
| 14 | Waste disposal bins (color coded) | 3 Bins per Candidate |
| 15 | Plain paper | 2 Sheets per Candidate |
| 16 | Pen | 1 Pc per Candidate |
| 17 | Assistant | 1 per Candidate |
| Items to be Evaluated | Marks Available | Marks Obtained | Comments |
|---|---|---|---|
| TASK 1: Prepare self and environment | |||
| Performed social hand wash before donning PPE (Award 1 mark or zero) | 1 | ||
| Donning appropriate PPEs: utility gloves, mackintosh apron, headgear, surgical mask, goggles (Award 1 mark for each appropriate PPE worn) | 5 | ||
| Prepared antiseptic solution and materials at hand (Award 1 mark or zero) | 1 | ||
| Sub-Total | 7 | ||
| TASK 2: Perform skin cleansing | |||
| Adjusted water tap and wetted hands with running water (Award 1 mark or zero) | 1 | ||
| Applied enough soap and rubbed hands thoroughly (Award 1 mark or zero) | 1 | ||
| Rinsed hands under running water (Award 1 mark or zero) | 1 | ||
| Dried hands with sterile towel without contamination (Award 1 mark or zero) | 1 | ||
| Donned sterile gloves maintaining sterility (Award 1 mark or zero) | 1 | ||
| Sub-Total | 5 | ||
| TASK 3: Perform skin antiseptic application | |||
| Instructed assistant to expose surgical site maintaining asepsis (Award 1 mark or zero) | 1 | ||
| Used sterile cotton swabs to apply antiseptic solution starting from center outward (Award 1 mark for correct technique and 1 mark for direction) | 2 | ||
| Covered entire 15 cm x 15 cm surgical site area uniformly (Award 1 mark for correct area coverage and 1 mark for even application) | 2 | ||
| Avoided contamination by not touching non-sterile surfaces (Award 1 mark or zero) | 1 | ||
| Disposed used materials in the correct color-coded bins (Award 1 mark or zero) | 1 | ||
| Sub-Total | 7 | ||
| TASK 4: Complete procedure and documentation | |||
| Removed PPE appropriately without contamination (Award 1 mark or zero) | 1 | ||
| Performed social hand wash after doffing PPE (Award 1 mark or zero) | 1 | ||
| Documented procedure performed including antiseptic used, site, and time (Award 1 mark for completeness and 1 mark for accuracy) | 2 | ||
| Sub-Total | 4 | ||
| PRODUCT CHECKLIST | |||
| Surgical site skin area cleansed and antiseptic applied uniformly over 15 cm x 15 cm area (Award 5 marks for correct size and uniform antiseptic application) | 5 | ||
| Sub-Total | 5 | ||
| GRAND TOTAL | 28 | ||