Title Page

  • Conducted on

  • Prepared by

  • Location

  • Department

  • Department

  • Department

  • Department

  • Specify

  • * = AORN Recommendation and/or Regulatory requirement.

  • ** = AHS Policy

Surgical Attire Observations

Observation #1

  • 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 #2

  • 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 #3

  • 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 #4

  • 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 #5

  • 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 #6

  • 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 #7

  • 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 #8

  • 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

  • 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

  • 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

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