Surgical Team Evaluation Form
Evaluate a surgical team’s performance after a procedure using structured ratings and feedback.
Case and Team Details
Procedure Date / Evaluation Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Surgical Department / Unit
*
Please Select
General Surgery
Orthopedics
Cardiothoracic
Neurosurgery
Obstetrics & Gynecology
Urology
ENT
Other
Procedure Type / Surgery Category
*
Surgical Team Evaluated
*
Surgical Team Evaluation
Overall Performance Rating
*
Poor
1
2
3
4
Excellent
5
1 is Poor, 5 is Excellent
Team Evaluation Criteria
*
Rows
1 - Poor
2 - Fair
3 - Good
4 - Very Good
5 - Excellent
Communication
1
2
3
4
5
Preparedness
6
7
8
9
10
Sterile Technique
11
12
13
14
15
Teamwork
16
17
18
19
20
Efficiency
21
22
23
24
25
Patient Safety
26
27
28
29
30
Overall Outcome
*
Please Select
Excellent
Satisfactory
Needs Improvement
Key Strengths Observed
Areas for Improvement
Feedback and Follow-up
Improvement Suggestions
Is further review or action needed?
*
Yes
No
Submit
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