Members Login

APS: Laparoscopic Hysterectomy

Please note that your information is saved on our server as you fill out this form.

  • Procedure: Laparoscopic Hysterectomy

  • Trainee / Assessor Details

  • DD slash MM slash YYYY

  • Please rate the trainee in the domains below using the following scale: N = Not observed or not appropriate, D = Development required, S = Satisfactory standard for completion of this procedure (no prompting or intervention required) or score on the Global Rating Scale
  • Communicates appropriately with patient
  • Communicates appropriately with assistant, anaesthetist and theatre staff
  • Demonstrates appropriate pre-operative preparation: institution’s safety check, patient bladder management
  • Demonstrates appropriate operative preparation: patient preparation and positioning, patient bladder management, DVT prophylaxis, IV antibiotics
  • Employs appropriate primary entry technique
  • Employs appropriate secondary port insertion
  • Appropriate vaginal, uterine, and/or rectal manipulation
  • Appropriate intra-operative assessment
  • Employs appropriate respect for tissue

  • Respect for Tissue Global Rating Scale

  • Demonstrates appropriate time and motion

  • Time and Motion Global Rating Scale

  • Employs appropriate instrument handling

  • Instrument Handling Global Rating Scale

  • Demonstrates appropriate knowledge of instruments

  • Knowledge of Instruments Global Rating Scale

  • Demonstrates appropriate use of assistants

  • Use of Assistants Global Rating Scale

  • Demonstrates appropriate flow of operation and forward planning

  • Flow of Operation and Forward Planning Global Rating Scale

  • Demonstrates appropriate knowledge of specific procedure

  • Knowledge of Specific Procedure Global Rating Scale

  • Correctly identifies anatomical structures and surgical spaces
  • Recognizes own limitations
  • Manages any complications effectively & efficiently
  • Appropriately completes procedure, closes incisions
  • Devises appropriate post-operative management plan

  • Verbal Feedback is a mandatory component of this assessment.

  • Please use this space to record areas of strength which were highlighted during discussion with the trainee.
  • Please use this space to record suggestions for development which were highlighted during discussion with the trainee.
  • After summarising the discussion with the trainee in the boxes above, please complete the level at which the procedure was performed on this occasion. Please note: For a SUMMATIVE ASSESSMENT, the trainee must be assessed as Level 4 "Competent to perform the procedure unsupervised or independently".
  • You will receive an automated confirmation email once this form has been submitted.
  • This field is for validation purposes and should be left unchanged.
Save and Continue Later

Scroll to Top