Surgical Procedure Checklist
Pre-Operative Verification Checklist
|Scheduling Verification |
|Review critical scheduling information with scheduler: | | |
|If scheduling information provided via telephone: | | |
|( ) schedulers perform a read-back of scheduling information | | |
|( ) completed procedure request form is received from facility scheduler | | |
|( ) reconcile scheduled procedure with procedure request form | | |
| | | |
|If procedure is scheduled electronically directly into the scheduling system: | | |
|Scheduling information is verified by at least independent reviewers. | | |
| |
|Pre-Admission Verification |
|Verify source documents are received (minimum 24 hours prior to procedure) | | |
| | | |
|Verify source documents match scheduled procedure | | |
| | | |
| | | |
|Pre-Op Verification |
|Person completing procedure information on informed consent verifies patient, procedure and location with source documents | | |
| | | |
|Pre-Operative Area | | |
|Patient identification verified using two indicators | | |
|Procedure verified using at least two independent source documents | |
|Provider order, diagnostic images, radiology/pathology reports, patient understanding of the procedure, informed consent | |
| | | |
| | |
|Procedure verified by at least two independent reviewers | | |
| | | |
|Site marked by person performing the procedure with initials: | | |
| | | |
|Multiple sites labeled in the medical record and marked accordingly | | |
| | | |
|Diagram marked by surgeon if unable to mark on patient or mark not visible with draping | | |
|Site was not marked due to: | | |
|( ) Site marking not required | | |
|( ) Provider is in continuous attendance with the patient | | |
|( ) Refused by patient | | |
| | | |
|Pre-Op Nurse Signature: | | |
| | | |
| | | |
| | | |
| | | |
| | | |
| | | |
| | | |
| | | |
| | | |
| | | |
|Operating Room | | |
|Team communication completed | | |
| | | |
|Team reviewed relevant case information including: | | |
| | | |
|( ) Images and diagnostic/pathology reports | | |
|( ) Implants or special equipment | | |
|( ) Antibiotics | | |
|( ) Positioning | | |
|( ) Any additional safety precautions | | |
|Time-out visual reminder placed over instrument tray | | |
| | | |
| | | |
|Operating Room — Just Prior to Incision | | |
|Surgeon initiated the time-out verbally | | |
| | | |
|All other activity ceased | | |
| | | |
|RN verbally verified patient and procedure including side/site | | |
| | | |
|ACP verbally verified patient and procedure including side/site | | |
| | | |
|Scrub Tech verbally verified procedure prepped and visualization of mark | | |
| | | |
|Surgeon verbally verified procedure including side/site | | |
| | | |
|Circulating Nurse Signature: | | |
| | | |
................
................
In order to avoid copyright disputes, this page is only a partial summary.
To fulfill the demand for quickly locating and searching documents.
It is intelligent file search solution for home and business.
Related searches
- first surgical procedure was done
- surgical procedure definition
- surgical procedure steps
- ambulatory surgical procedure codes
- surgical procedure vs medical procedure
- asc surgical procedure list
- cms surgical procedure guidelines
- surgical procedure documentation guidelines
- surgical procedure for degenerative disc
- icd 9 surgical procedure codes
- surgical procedure note template
- common surgical procedure abbreviations