Surgical Pause/ Time-Out Form
[Pages:1]Surgical Pause/ Time-Out Form
This suggested form is to be used to perform the Pause or Time-Out in the pre-operative area by an anesthesiologist and the surgeon in the operating room just prior to beginning the procedure on the patient. A separate form should be used for each procedure.
Date: ________________ Patient Identification
Choose two (2) or more of the following identifiers: Name: Assigned ID #: Telephone #: Date of Birth: Social Security #: Address: Photograph:
Name of Surgeon(s): Procedure: Procedure Site:
Procedure Identification Procedure Side:
Time of Pause:
Identification of Patient
Identification of Procedure Identification
of Site Identification
of Side
Pause/ Time-Out
Verbal Confirmation by Surgeon
Confirmation by Assisting Team
Member
Identifier Identifier Identifier Identifier
#1
#2
#1
#2
Name of Team Member Confirming
Team Members Present
Name, License # or Title If Applicable:
Date:
Draft 02/2014
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