Surgical Precision Evaluation Survey
Please complete this survey to evaluate surgical precision and technique during the observed procedure.
Evaluator Full Name
*
First Name
Last Name
Evaluator Role
*
Please Select
Surgeon
Surgical Assistant
Nurse
Observer
Other
Date of Procedure
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Type of Surgical Procedure
*
Please Select
General Surgery
Orthopedic Surgery
Cardiac Surgery
Neurosurgery
Plastic Surgery
Other
Please rate the following aspects of surgical precision:
*
Rows
Poor
Fair
Good
Very Good
Excellent
Accuracy of Incision
1
2
3
4
5
Instrument Handling
6
7
8
9
10
Tissue Handling
11
12
13
14
15
Hemostasis Technique
16
17
18
19
20
Adherence to Sterile Technique
21
22
23
24
25
Steadiness of Hand During Procedure
*
1
2
3
4
5
Communication with Surgical Team
*
Poor
1
2
3
4
Excellent
5
1 is Poor, 5 is Excellent
Were there any observable errors or deviations from protocol?
*
No errors observed
Minor errors, corrected promptly
Significant errors, required intervention
Overall Impression of Surgical Precision
*
Outstanding
Very Good
Good
Needs Improvement
Additional Comments or Observations
Submit Evaluation
Should be Empty: