UNITED DOCTORS MEDICAL CENTER

Quezon City

NURSES PRE-OPERATIVE / PROCEDURE CHECKLIST

Name ______________________________________ Rm. / Bed No. ___________ Hosp. No ________

Last First M.I.

Age: _____________ Attending Physician: ____________________________________

Weight: ___________ Date of Operation / Procedure to be done: ____________________ Time: _____

Type of operation procedure/Procedure _____________________________________________________

Name of Surgeon: ____________________________ Anesthesiologist: ___________________________
Schedule slip sent: Yes ( ) No ( ) Anesthesia: _______________________________
By whom: ______________________

Pre-Op Meds Given: Yes ( ) No ( ) Vital Signs: Date / Time / Sig.

Date: Time: Sig. T=
_____________________________ P=
_____________________________ RR =
_____________________________ B/P =

IVF given: Date / Time / Sig.

_________________________

NPO: Yes ( ) No ( )
Valid Consent Signed: Yes ( ) No ( )
by whom: _________________________________
patient/relative

External Prep done by: ______________________________ Check by: ________________________

Pre-Op bath shower: Yes ( ) No ( ) Lab Exams: (if ordered)

History of allergy: Yes ( ) No ( ) Blood on Chart ( ) sent to Lab ( )
History of PE: Yes ( ) No ( ) Urine on Chart ( ) sent to Lab ( )
Chest & back Exam: Yes ( ) No ( ) ECG on Chart ( ) sent to Lab ( )
X-ray on Chart ( ) sent to X-ray ( )

Treatments: (if ordered)

Enema : Yes ( ) No ( )
Catheterized (retain & clamp) : Yes ( ) No ( )
Vaginal irrigation : Yes ( ) No ( )
Others: _____________________________________

Chaplain Visit: Yes ( ) No ( ) Date: __________ Time: __________

Hospital consent for sterilization signed by: ____________________________
patient/relative
(Signature over Printed Name)

Physical Prep: Checked by: ________________

() False teeth removed

() Hair pins removed
() Jewellery removed
() Nail polish removed
() Underwear removed
() Voided
Before Operation / Procedure

Endorsed by: _______________________ Received / Final check by: _______________________

Floor / Ward Nurse OR / Ancillary Personnel

Wheeled by: __________________________________ Date / Time: _________________________

Ward Orderly / Nursing Aide

Date / Time: __________________________________

After Operation / Procedure:

Endorsed by: _______________________ Received / Final check by: _______________________

OR / Ancillary Personnel Floor / Ward Nurse

Wheeled by: __________________________________ Date / Time: _________________________

Ward Orderly / Nursing Aide

Date / Time: __________________________________

Ns-form/preopchec/lrdc