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STERILE TRAY

STERILE TRAY SET-UP

Student:

Clinical Affiliate: Date:

The following checklist is designed to assess the student’s ability to set up a sterile field, open packages and transfer sterile items without contamination.

EVALUATOR INSTRUCTIONS:

Evaluate the student’s performance on each task by checking the appropriate box.

If the task is not performed during the procedure, the student is to SIMULATE it.

Incomplete forms willnot be accepted

YES	NO	NP	NA
Completed	Did NOT complete	Needs practice	Not applicable.

CIRCLE the procedure being observed:

Arthrogram Facet Block Rhizotomy HSP Other (designate procedure)

Prepare for examination

YES	NO	NP	NA		TASK
				1.	Provides a clean, orderly work area and obtains necessary supplies.

Opening of sterile tray

YES	NO	NP	NA		TASK
				2.	Wash hands.
				3.	Place tray on clean table/surface with sealed end towards student.
				4.	Open corner 1 back and away from the pack.
				5.	Opens corner 2 and 3 to the left and right.
				6.	Open corner 4 and drop it towards your body.
				7.	Do not touch the sterile contents of the tray.

Opening sterile packs and supplies. Dropping onto a sterile tray

YES	NO	NP	NA		TASK
				8.	Hold the sterile pack or supply in front and away from body.
				9.	Pull tabs apart without touching contents.
				10	Reach slightly over the sterile field and several inches above the sterile field.
				11.	Drop the contents of the pack onto the field.
				12.	Do not touch sterile item or sterile tray.

Sterile person to grasp contents

YES	NO	NP	NA		TASK
				13.	Hold sterile pack or supply in front and away from body.
				14.	Pull tabs apart without touching contents.
				15.	Open sterile pack allowing the corners to fall over your hand.
				16.	Present contents to sterile person.
				17.	Pull the wrapping in the opposite direction.

Pour liquid to sterile field

YES	NO	NP	NA		TASK
				18.	Open bottle of liquid.
				19.	Do not touch rim of bottle.
				20.	Pour off small amount into waste basket/sink to clean bottle rim.
				21.	Hold bottle slightly over the sterile field and above the sterile field.
				22.	Pour contents into designated receptacle.
				23.	Clean and dispose of sterile tray and contents using Standard Precautions.

Patient-technologist (student) relationship

YES	NO	NP	NA		TASK
				24.	Select correct patient, assess patient’s condition, assist patient.
				25.	Give proper explanation of procedure.
				26.	Assist the patient throughout exam while maintaining patient modesty.
				27.	Obtain history prior to exam and document.
				28.	Monitor and communicate with the patient throughout the exam.

COMMENTS:

After observing _________________________ setting up a sterile tray and opening sterile packages, I feel that he/she is competent to perform this task with minimal assistance.

EVALUATOR’S SIGNATURE: DATE:

STUDENT’S SIGNATURE: DATE:

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