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Basic Procedure Form
STCC Surgical Technologist Program
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Select your name: *
Select your STCC-assigned e-mail address: *
Procedure Name: *
Date of procedure (use dropdown selector): *
MM
/
DD
/
YYYY
Surgical Team:
Surgeon: *
CST: *
RN: *
Surgery Type:
If specialty was chosen above,  select type:
Definition of Procedure: *
Pathophysiology (condition/indication for procedure): *
Diagnostic/Pre-OP Testing *
Type of Anesthesia (check all that apply): *
Required
If other than "General" was selected above, please comment:
Patient position/positioning equipment: *
Patient Safety Considerations: *
Describe Area of Skin Prep, What Agent, & Why: *
Draping Sequence: *
List Any Specialty Sterile Supplies (i.e. harmonic, ligasure, mesh etc.) or Instruments: *
List Any Non-Sterile Equipment: *
Medication on the Field: *
Instrument Sets: *
Specialty Instruments: *
Counts
Initial: *
Required
First Closing: *
Required
Final Closing: *
Required
MMC: *
Required
Final Sharps: *
List Suture Used (type, size, needle, & what layer): *
Dressing: *
Specimen Identified As: *
How Was Specimen Handled? *
Postoperative Destination: *
Required
Wound Classification: *
Summary of procedure (in your own words, incision to dressing): *
How did you participate in this case (be specific)? *
Comments/complications (did case go well)? *
By submitting this form, you are attesting that you are the individual named above who has been directly assigned the selected STCC e-mail address according to STCC policy. All submissions are subject to validation review by STCC faculty, staff, and/or accrediting bodies. *
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