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Perform Scrub Person Role in <Insert Specialty>

Surgery <Insert Facility Name Here>

This checklist is designed for use with multiple roles and can be used as an electronic document or printed out and completed
manually. Please complete the sections on this page by placing an X or marking as N/A in the box provided.

Date: Name/Title: Evaluator:

Competency Priority Code Self-Assessment

Initial competency (must be completed at orientation) Can perform without assistance
Completion within 90 days Need assistance to perform
Completion within 6 months Need supervision when performing
Specialty competency Unable to perform

Pre-requisites
Didactic (see reading list in next section)
Complete basic unit orientation
Meet Perform in the Scrub Person Role competency
Basic Life Support (BLS)

Pre-requisites-Required Reading (all references current edition unless noted)

AORN Guidelines for Perioperative Practice: (as called out in the Perform in the Scrub Person Role competency)
AORN Tool Kits: Fire Safety, Sharps Safety, Management of Surgical Smoke
Rothrock, JC.(ed) Alexander’s Care of the Patient in Surgery—Unit 1: Foundations for Practice; Unit 2: Surgical Interventions
(relevant specialty chapters); Chapter 26: Pediatric Surgery; Chapter 27: Geriatric Surgery
Unit Policy/Procedure/Clinical Guidelines

Competency Elements
Please note: Not all attributes may be applicable to the role you are evaluating. Each attribute is worth one point. If the attribute is met,
mark a “1” in the Met column. If the attribute is not met, mark a “0” in the Not Met column. If an attribute does not apply to the
situation or role, please mark it as N/A. Note the skill code in the skill code column. Use the comments section to make any notes
about how the attribute was handled. Total the score in the space provided.

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Competency Assessment Checklists 44-2

Performance Codes Recommended Validation

Please use the following codes to indicate the method of skill validation:
DS: Return demonstration—Simulated
DA: Return demonstration—Actual (real time in actual procedure)
V: Verbal explanation
C: Case Study

Met Not Met N/A Skill Code Comments

1 point 0 point 0 point
Describe scope of selected surgical specialty care
(e.g., general [gastrointestinal {GI}, hernia,
liver/biliary/spleen, thyroid/parathyroid, breast,
minimally invasive, bariatric], genitourinary,
plastic/ reconstructive, otorhinolaryngologic,
ophthalmic, gynecologic/ obstetric, orthopedic,
hand, oral maxillofacial, neurosurgery, thoracic,
vascular, cardiac, pediatric, geriatric, trauma,
transplantation, oncologic).
List elective surgical procedures performed for
specialty (e.g., high volume, low volume, high
risk) in facility/unit.
Identify specialty staff, resource and support
persons on team (e.g., registered nurse first
assistants, physician assistants, perfusionists,
radiology technologists, neural monitoring
technologists, biomedical technical support).
Select three most commonly performed surgeries
in selected specialty and demonstrate/describe
independent practice in the scrub person role:
 Describe basic relevant surgical anatomy and
physiology of surgical diagnosis for selected
surgical procedure (e.g., GI tract pathway and

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Competency Assessment Checklists 44-3

digestion before and after bariatric surgery).

 Describe indication for selected procedure (e.g.,
malignancy, obstruction, fracture) and desired
outcome (e.g., malignancy disease-free
survival, pain relief, weight loss).
 Describe potential complications (e.g.,
hemorrhage, infection, obstruction) and
intraoperative hazards (e.g., radiation, laser, fire
risk).
 Describe anesthesia-related implications (e.g.,
thermal management, blood
transfusion/autologous blood collection, airway
challenges).
 Describe surgical process from incision to
closure (e.g., incision site,
compartment/region/cavity entered, isolation
[bowel/malignancy] technique for contaminated
instruments, structures/tissue dissected,
repair/anastomosis/excision, drains/implants,
closure, dressing/cast).
 Identify/select appropriate surgeon
preference/pick-list.
 Identify/describe specialty instruments and
supplies (e.g., laparotomy set, self-retaining
abdominal retractor, dermatome, drill).
 Identify/describe specialty equipment and
devices (e.g., microscope, electrosurgical unit
[ESU], laser, ultrasonic dissector, surgical
robot).
 Demonstrate competency to prepare, operate,
and troubleshoot each listed device and
equipment from the sterile field. Employ
protective safety measures (e.g., ESU pencil in

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Competency Assessment Checklists 44-4

holster, moist towels around incision area

during laser use, smoke evacuation).
 Identify/describe specialty tables and
positioning devices (e.g., orthopedic table,
vacuum/beanbag positioner, stirrups).
 Demonstrate competency to prepare, operate,
and troubleshoot each listed specialty table and
positioning devices.
 Describe patient position for procedure and
specific patient and staff risks for injury.
 Describe drapes, draping procedure, staff
positions at sterile field, equipment placement.
 Describe scrub person role during
intraoperative radiologic studies/fluoroscopy
(e.g., shielding patient and staff, positioning,
assisting radiology technologist, accepting
cassette into sterile bag, draping C-arm,
monitoring integrity of sterile field).
 Identify/describe specialty implants (e.g.,
orthopedic nails, screws, rods, plates, silicone,
cochlear, tissue implants [autologous bone,
ligaments, skin, valves, transplant organs],
shunts).
 Describe facility policy/procedure for
radioactive implant care and handling (e.g.,
radioactive substances, protective measures,
radiation oncology role).
 Describe facility/unit process for tissue tracking
(e.g., tissue storage, log books/electronic
documentation, special handling/reconstitution,
patient record documentation).
 Identify/describe specialty medications,

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Competency Assessment Checklists 44-5

solutions, and hemostatic agents (e.g.,

antibiotics, local anesthetics, radiopaque
contrast dye, heparin solution, collagen/fibrin
sheets, powder).
 Identify/describe specialty sutures (e.g.,
retraction sutures, ties/hemostatic ligatures,
anastomotic sutures, blunt point, support
sutures, mechanical stapling devices, suture for
closure).
 Demonstrate/describe accurate instrument and
suture passing. Employ neutral/safe zone in
collaboration with sterile team members.
 Describe corrective action for suture/needle
miscount/unresolved count.
 Identify/describe specialty specimen care and
handling (e.g., routine histology, frozen section,
cultures, cytology washings, specimens for
disposal, radioactive substances, forensic
evidence, patient take-home specimens [when/if
indicated, retained hardware removal], and
foreign bodies).
 Describe wound closure, dressings, drains,
preparation for transfer.
 Describe relevant patient information to be
delivered during handoff/over report to scrub
person at temporary and permanent relief.
Totals

Scoring Interpretation

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Competency Assessment Checklists 44-6

Total Score Zone

25 to 28 Points (85%-100%) Mastery Zone
20 to 24 Points (70%-84%) Building Zone
19 and Below (69% and Less) Developing Zone

Action Plan:

Learner Goals and Time frame:

Use the space below to take any additional notes:

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