Title Page
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Conducted on
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Prepared by
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Location
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Department
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Department
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Department
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Department
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Specify
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* = AORN Recommendation and/or Regulatory requirement.
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** = AHS Policy
Surgical Attire Observations
Observation #1
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Who was observed?
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Specify:
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Type of area
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Visibly clean scrubs. */**
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Removes visibly soiled scrub attire as soon as possible and dons clean attire. */**
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Personal clothing contained within scrub attire. */**
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If 2 pc scrubs, top of scrub suit secured at the waist or tucked into pants. **
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Surgical head cover/hood covers all hair and scalp skin. */**
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If bearded, beard cover covers all facial hair. */**
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Mask not hanging around neck. **
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Shoe covers worn for wet procedures and when appropriate. */**
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If used, shoe covers removed immediately after use, and hand hygiene performed. */**
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Jewelry contained within scrub attire. **
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Comments
Observation #2
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Who was observed?
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Specify:
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Type of area
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Visibly clean scrubs. */**
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Removes visibly soiled scrub attire as soon as possible and dons clean attire. */**
-
Personal clothing contained within scrub attire. */**
-
If 2 pc scrubs, top of scrub suit secured at the waist or tucked into pants. **
-
Surgical head cover/hood covers all hair and scalp skin. */**
-
If bearded, beard cover covers all facial hair. */**
-
Mask not hanging around neck. **
-
Shoe covers worn for wet procedures and when appropriate. */**
-
If used, shoe covers removed immediately after use, and hand hygiene performed. */**
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Jewelry contained within scrub attire. **
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Comments
Observation #3
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Who was observed?
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Specify:
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Type of area
-
Visibly clean scrubs. */**
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Removes visibly soiled scrub attire as soon as possible and dons clean attire. */**
-
Personal clothing contained within scrub attire. */**
-
If 2 pc scrubs, top of scrub suit secured at the waist or tucked into pants. **
-
Surgical head cover/hood covers all hair and scalp skin. */**
-
If bearded, beard cover covers all facial hair. */**
-
Mask not hanging around neck. **
-
Shoe covers worn for wet procedures and when appropriate. */**
-
If used, shoe covers removed immediately after use, and hand hygiene performed. */**
-
Jewelry contained within scrub attire. **
-
Comments
Observation #4
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Who was observed?
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Specify:
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Type of area
-
Visibly clean scrubs. */**
-
Removes visibly soiled scrub attire as soon as possible and dons clean attire. */**
-
Personal clothing contained within scrub attire. */**
-
If 2 pc scrubs, top of scrub suit secured at the waist or tucked into pants. **
-
Surgical head cover/hood covers all hair and scalp skin. */**
-
If bearded, beard cover covers all facial hair. */**
-
Mask not hanging around neck. **
-
Shoe covers worn for wet procedures and when appropriate. */**
-
If used, shoe covers removed immediately after use, and hand hygiene performed. */**
-
Jewelry contained within scrub attire. **
-
Comments
Observation #5
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Who was observed?
-
Specify:
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Type of area
-
Visibly clean scrubs. */**
-
Removes visibly soiled scrub attire as soon as possible and dons clean attire. */**
-
Personal clothing contained within scrub attire. */**
-
If 2 pc scrubs, top of scrub suit secured at the waist or tucked into pants. **
-
Surgical head cover/hood covers all hair and scalp skin. */**
-
If bearded, beard cover covers all facial hair. */**
-
Mask not hanging around neck. **
-
Shoe covers worn for wet procedures and when appropriate. */**
-
If used, shoe covers removed immediately after use, and hand hygiene performed. */**
-
Jewelry contained within scrub attire. **
-
Comments
Observation #6
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Who was observed?
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Specify:
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Type of area
-
Visibly clean scrubs. */**
-
Removes visibly soiled scrub attire as soon as possible and dons clean attire. */**
-
Personal clothing contained within scrub attire. */**
-
If 2 pc scrubs, top of scrub suit secured at the waist or tucked into pants. **
-
Surgical head cover/hood covers all hair and scalp skin. */**
-
If bearded, beard cover covers all facial hair. */**
-
Mask not hanging around neck. **
-
Shoe covers worn for wet procedures and when appropriate. */**
-
If used, shoe covers removed immediately after use, and hand hygiene performed. */**
-
Jewelry contained within scrub attire. **
-
Comments
Observation #7
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Who was observed?
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Specify:
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Type of area
-
Visibly clean scrubs. */**
-
Removes visibly soiled scrub attire as soon as possible and dons clean attire. */**
-
Personal clothing contained within scrub attire. */**
-
If 2 pc scrubs, top of scrub suit secured at the waist or tucked into pants. **
-
Surgical head cover/hood covers all hair and scalp skin. */**
-
If bearded, beard cover covers all facial hair. */**
-
Mask not hanging around neck. **
-
Shoe covers worn for wet procedures and when appropriate. */**
-
If used, shoe covers removed immediately after use, and hand hygiene performed. */**
-
Jewelry contained within scrub attire. **
-
Comments
Observation #8
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Who was observed?
-
Specify:
-
Type of area
-
Visibly clean scrubs. */**
-
Removes visibly soiled scrub attire as soon as possible and dons clean attire. */**
-
Personal clothing contained within scrub attire. */**
-
If 2 pc scrubs, top of scrub suit secured at the waist or tucked into pants. **
-
Surgical head cover/hood covers all hair and scalp skin. */**
-
If bearded, beard cover covers all facial hair. */**
-
Mask not hanging around neck. **
-
Shoe covers worn for wet procedures and when appropriate. */**
-
If used, shoe covers removed immediately after use, and hand hygiene performed. */**
-
Jewelry contained within scrub attire. **
-
Comments
Observation #9
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Who was observed?
-
Specify:
-
Type of area
-
Visibly clean scrubs. */**
-
Removes visibly soiled scrub attire as soon as possible and dons clean attire. */**
-
Personal clothing contained within scrub attire. */**
-
If 2 pc scrubs, top of scrub suit secured at the waist or tucked into pants. **
-
Surgical head cover/hood covers all hair and scalp skin. */**
-
If bearded, beard cover covers all facial hair. */**
-
Mask not hanging around neck. **
-
Shoe covers worn for wet procedures and when appropriate. */**
-
If used, shoe covers removed immediately after use, and hand hygiene performed. */**
-
Jewelry contained within scrub attire. **
-
Comments
Observation #10
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Who was observed?
-
Specify:
-
Type of area
-
Visibly clean scrubs. */**
-
Removes visibly soiled scrub attire as soon as possible and dons clean attire. */**
-
Personal clothing contained within scrub attire. */**
-
If 2 pc scrubs, top of scrub suit secured at the waist or tucked into pants. **
-
Surgical head cover/hood covers all hair and scalp skin. */**
-
If bearded, beard cover covers all facial hair. */**
-
Mask not hanging around neck. **
-
Shoe covers worn for wet procedures and when appropriate. */**
-
If used, shoe covers removed immediately after use, and hand hygiene performed. */**
-
Jewelry contained within scrub attire. **
-
Comments