Initial FPPE_Non-Physician Surgery First Assist Proctoring Form

Non-Physician Surgical First Assist Proctoring Form
Non-Physician Surgical First Assist : _____________________________________________________ ( print ) Supervising Physician : _______________________________________________________________ ( print )
� FPPE / New Privileges FPPE / Focused Review OPPE / Reappointment
Charts Reviewed : 50 surgical hours of first assisting required in first 6 months
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Surgery Date :
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Total Time : ( minutes )
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Total Time : ( minutes )
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Total Time : ( minutes )
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Total Time : ( minutes )
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Total Time : ( minutes )
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Total Time : ( minutes )
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Total Time : ( minutes )
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Total Time : ( minutes )
Surgery Date :
MRN :
Procedure :
Total Time : ( minutes )
Surgery Date :
MRN :
Procedure :
Total Time : ( minutes )
Review Form Revision : 11 / 20 / 2019 MM Page 1 of 5