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Pre-Operative Checklist Sample

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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Jane Dey
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578 views2 pages

Pre-Operative Checklist Sample

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.

Uploaded by

Jane Dey
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

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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