Surgical Procedure Log Book Student s Name:
Direction for verifying surgical procedures in the Surgical Procedure Log book. Only record the surgical procedures in which you have performed in the role of the first scrub (* please see below for definition). Use Black Ballpoint pen. Use one line per procedure. Complete the date of procedure. Initial under proper heading categorizing the procedure under one of six headings. (Please see examples for each surgical specialty). Complete Verification of Surgical Experience Form. First Scrub: The surgical team member who gowns and gloves self, creates the sterile field by setting up the backtable and Mayo stand, gowns and gloves the surgeon and other members of the surgical team, maintains and governs aseptic technique of the sterile field, does all required counts, and is the primary handler of instruments, supplies, and equipment.
The following is a list of examples of general surgical procedures. It is not inclusive, but serves as a guideline for categorizing your surgical experiences. Abdominal Perineal Resection Appendectomy: Open or Laparoscopic Breast Biopsy Cholecystectomy: Open or Laparoscopic Cholecystostomy Colon Resection: Open or Laparoscopic Common Bile Duct Exploration Diaphragmatic Hernia Draining Pancreatic Cyst Esophagectomy Esophagogastrectomy Esophagomyotomy Excision of Pilonidal Cyst Femoral Hernia Fistulotomy/Fistulectomy Gastrectomy/Gastroplasty Gastroduodenostomy Gastrojejunostomy Gastrostomy Groshong Catheter Insertion Hemorrhoidectomy Incisional Hernia Inguinal Hernia: Open or Laparoscopic Modified Radical Mastectomy Liver Biopsy Liver Resection Nissen Fundoplication:Open or Laparoscopic Parathyroidectomy Pyloroplasty Roux en-y Sigmoidoscopy Small Bowel Resection Splenectomy: Open or Laparoscopic Thyroidectomy Tracheotomy &Tracheostomy Umbilical Hernia Vagotomy
Vascular Access Procedures Vein Ligation & Stripping Ventral Hernia Whipple Pancreaticoduodenectomy
The following is a list of examples of gynecologic and obstetrical surgical procedures. It is not inclusive, but serves as a guideline for categorizing your surgical experiences. Abdominal Hysterectomy Anterior & Posterior Repair Basic Colposcopy Biopsy of Vulva Cervical Biopsy Cryotherapy, Laser Treatment, LEEP, and Conization Cesarean Section Cone Biopsy D & C with or without suction Diagnostic Laparoscopy Ectopic Pregnancy Excision of Vulvar Skin Hysteroscopy Laparoscopic-Assisted Vaginal Hysterectomy Marshall-Marchetti-Kranz or RAZ Marsupialization of Bartholin's Cyst Myomectomy Oopherectomy Pelvic Exenteration Salpingectomy Tubal Ligation Tuboplasty Uterine Suspension Vaginal Hysterectomy Vaginal Vault Suspension Vulvectomy
The following is a list of examples of genitourinary surgical procedures. It is not inclusive, but serves as a guideline for categorizing your surgical experiences. Adrenalectomy Biopsy of the Bladder Biopsy of the Prostate Circumcision Cystectomy/Ileal Conduit Cystoscopy Cystostomy Stone Removal Stent Insertion Hydrocele Hypospadius Internal Urethrotomy Nephrectomy Orehiectomy Orchiopexy Penile Implant Percutaneous Nephrostomy Radical Suprapubic Prostatectomy Renal Transplant Retropubic Prostactectomy Torsion of the Testicle Transurethral Resection of the Prostate (TURP) Transurethral Resection of the Bladder (TURB) Ureterolithotomy Vasectomy Vasovasostomy
The following is a list of examples of orthopedic surgical procedures. It is not inclusive, but serves as a guideline for categorizing your surgical experiences. Above-the-Knee or Below-the-Knee Amputation Arthroscopy Arthroscopic ACL Repair Arthroscopic Bankart Repair Arthroscopic Meniscal Repair Bunionectomy Cannulated Hip Screw Carpal Tunnel Release: Open or Endoscopic Closed IM Rod - Femur Closed IM Rod-Humerus Closed Reduction with pinning Hip Screw Compression Dupuytrens Contracture External Fixation of Lower Extremity External Fixation of the Upper Extremity External Fixation of the Pelvis Ganglion Excision Incision & Drainage ORIF Ankle ORIF Femur ORIF Fibula ORIF Radius ORIF Tibia ORIF Ulna Osteotomy Removal Hardware Repair of Rotator Cuff Triple Arthrodesis of the Ankle Total Hip Arthroplasty Total Knee Arthroplasty
The following is a list of examples of otorhinolaryngologic surgical procedures. It is not inclusive, but serves as a guideline for categorizing your surgical experiences. Bronchoscopy Caldwell-Luc Regular or endoscopic Esophagogastroduodenoscopy (EGD) Ethmoidectomy Regular or endoscopic Intranasal Antrostomy Laryngectomy Total or partial Laryngoscopy Lefort I, II, or III Mandibular Fracture Mastoidectomy Myringotomy Otoplasty Panendoscopy Parotidectomy Polypectomy Radial Neck Dissection Septoplasty Septorhinoplasty Sinoscopy Sphenoidectomy Stapedectorny Stapedotomy Submucous Resection (SMR) Tonsillectomy & Adenoidectorny (T&A) Turbinectomy Regular or endoscopic Tympanoplasty Regular or endoscopic Uvulopalatopharyngoplasty (UPPP)
VERIFICATION OF SURGICAL EXPERIENCE The following signature must be obtained to verify the first scrub role experience as documented in the Surgical Procedure Log Book. I, verify that has completed 125 surgical procedures in the first scrub role as documented in the Surgical Procedure Log Book. Operating Room Supervisor s Signature: Date Name and address of Facility: Telephone: E-mail:
SURGICAL PROCEDURE LOG 1st SCRUB Date: (month, day, and year) NAME OF PROCEDURE (one line per procedure) GENERAL GENITOURINARY GYNECOLOGY ORTHOPEDICS OTORHINOLARYNGOLOGY OTHER PROCEDURES
SURGICAL PROCEDURE LOG 1st SCRUB Date: (month, day, and year) NAME OF PROCEDURE (one line per procedure) GENERAL GENITOURINARY GYNECOLOGY ORTHOPEDICS OTORHINOLARYNGOLOGY OTHER PROCEDURES
SURGICAL PROCEDURE LOG 1st SCRUB Date: (month, day, and year) NAME OF PROCEDURE (one line per procedure) GENERAL GENITOURINARY GYNECOLOGY ORTHOPEDICS OTORHINOLARYNGOLOGY OTHER PROCEDURES
SURGICAL PROCEDURE LOG 1st SCRUB Date: (month, day, and year) NAME OF PROCEDURE (one line per procedure) GENERAL GENITOURINARY GYNECOLOGY ORTHOPEDICS OTORHINOLARYNGOLOGY OTHER PROCEDURES