Surgical Team Performance Review Form
Use this form to evaluate surgical team performance for a specific case or review period.
Review Context
Review Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Surgical Specialty / Service Line
*
Please Select
General Surgery
Orthopedics
Neurosurgery
Cardiovascular Surgery
Thoracic Surgery
Plastic Surgery
Urology
Gynecology
ENT (Otolaryngology)
Ophthalmology
Trauma Surgery
Other
Procedure Type / Case Category
Reviewer Role
*
Surgeon
Anesthesiologist
Nurse
OR Coordinator
Other
Performance Assessment
Surgical team performance assessment
*
Rows
1 - Poor
2 - Fair
3 - Good
4 - Very Good
5 - Excellent
Communication
1
2
3
4
5
Preparation
6
7
8
9
10
Teamwork
11
12
13
14
15
Sterile protocol adherence
16
17
18
19
20
Time management
21
22
23
24
25
Response to intraoperative issues
26
27
28
29
30
Overall communication
1
2
3
4
5
Overall teamwork
1
2
3
4
5
Overall procedural readiness
1
2
3
4
5
Overall Review
Overall Performance Rating
*
1
2
3
4
5
Strengths Observed
Improvement Opportunities
Follow-up Action Needed
*
No follow-up
Coaching
Case review
Escalation
Other
Submit Review
Should be Empty: