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  • Pre-Operative Checklist Sample

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    Jane Dey
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    The pre-operative checklist summarizes the preparation for a patient named B.C. for surgery on 01/04/2020. It confirms that the patient's ID band and surgical consent are in place, lists their allergies and notes they were NPO after midnight. It also checks that their operative site was prepared, labs were taken, vital signs were normal, and blood products were available and cross-matched as needed. Pre-op medications, toileting, oral care, bathing and jewelry/accessory removal were also completed, and the patient arrived in the holding area at 9:30 AM receiving IV fluids.

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    Pre-operative Checklist Sample

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    The pre-operative checklist summarizes the preparation for a patient named B.C. for surgery on 01/04/2020. It confirms that the patient's ID band and surgical consent are in place, lists their allergies and notes they were NPO after midnight. It also checks that their operative site was prepared, labs were taken, vital signs were normal, and blood products were available and cross-matched as needed. Pre-op medications, toileting, oral care, bathing and jewelry/accessory removal were also completed, and the patient arrived in the holding area at 9:30 AM receiving IV fluids.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
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    48 views2 pages

    Pre-Operative Checklist Sample

    Uploaded by

    Jane Dey
    The pre-operative checklist summarizes the preparation for a patient named B.C. for surgery on 01/04/2020. It confirms that the patient's ID band and surgical consent are in place, lists their allergies and notes they were NPO after midnight. It also checks that their operative site was prepared, labs were taken, vital signs were normal, and blood products were available and cross-matched as needed. Pre-op medications, toileting, oral care, bathing and jewelry/accessory removal were also completed, and the patient arrived in the holding area at 9:30 AM receiving IV fluids.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
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    of 2

    PRE-OPERATIVE CHECKLIST

    Name: B.C. Room/Ward: SLR Ward Date: 01/04/2020

    YES NO N/A
    1 ID Band ✓

    2 Surgical Consent Signed ✓

    3 Allergies: Penicillin ✓

    4 NPO since: 12:00 AM ✓

    5 Operative site prepared ✓

    6 CP Evaluation/ Clearance ✓

    7 Laboratories taken: Hgb: 90 g/L Hct: 0.41 L/L S.K: 5meq/L


    S.Na: 140 meq/L

    Others:
    Creatinine= 77 umol/L
    Cholesterol: 6.72 mmol/L
    Triglycerides: 1.32 mmol/L
    HDL Cholesterol: 6.72 mmol/L
    LDL Cholesterol: 5.11 mmol/L
    SGPT: 20 U/ L
    FBS: 6.19 mmol/L

    8 X-ray film/ CT scan & UTZ result: Chest X-ray PA View: Normal

    9 Vital signs: T: 36.5°C P: 88 bpm RR: 20 breathes/minute

    BP: 130/70 mmHg Wt: 201 lbs.

    10 Blood No. of Units No. of Units X-matched Not X-


    Available matched
    FWB 1 6 ✓

    PRBC 2 7 ✓

    FFP 2 10 ✓

    PRP 1-2 8 single- ✓


    injections dose
    injections
    Blood consent signed ✓

    11 Pre-op Medications / Treatment


    Name of Medications/ Treatment:
    Midazolam 15 mg ½ tab Time given: 30 minutes prior to OR
    CBG Monitoring Time given: 1 hour prior to OR
    Incentive Spirometry Time given: 10x /hour

    12 Voided: approximately 40 ml in the first hour (clear yellow urine)

    With Foley catheter: No

    13 SS/ Cleansing Enema ✓

    14 Oral Care ✓

    15 Bath Given ✓

    16 Removed:

    a. false dentures ✓

    b. jewelries
    ✓
    c. contact lens/hearing aide ✓

    d. underwear ✓

    e. nail polish ✓

    f. hair clips ✓
    To be filled out by OR Nurse

    Time of arrival in the Holding Area: 9:30 AM

    IV Fluids: D5LR Amount received: 125 cc/hr

    Checked by:_____________________ Received by:__________________________

    Name & Signatures of Ward Nurse Name & Signatures of OR Nurse

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