Surgical Review Procedure Evaluation Form
Please complete this form to provide a structured evaluation of the reviewed surgical procedure.
Reviewer Full Name
*
First Name
Last Name
Reviewer Role/Title
*
Department or Specialty
*
Date of Review
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Surgical Procedure Name
*
Procedure Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Patient Identifier (Anonymized)
*
Overall Assessment of the Surgical Procedure
*
1
2
3
4
5
Please rate the following aspects of the procedure:
*
Rows
Poor
Fair
Good
Very Good
Excellent
Preoperative Planning
1
2
3
4
5
Aseptic Technique
6
7
8
9
10
Surgical Technique
11
12
13
14
15
Intraoperative Decision Making
16
17
18
19
20
Team Communication
21
22
23
24
25
Patient Safety Measures
26
27
28
29
30
Were there any intraoperative complications?
*
No
Yes
If yes, please describe the complication(s) and management:
Patient Outcome (select the most appropriate)
*
Please Select
Full Recovery
Minor Complications
Major Complications
Ongoing Recovery
Other
Additional Comments or Recommendations
Submit Review
Should be Empty: