PRE-OPERATIVE CHECKLIST

Name of patient:
Age: Sex: Ward/room:
Diagnosis:
Proposed Operation:
Anesthesia: Anesthesiologist: Surgeon:

INSTRUCTION: Please check appropriate column

DATE/ COMMENTS
YES NO REMARKS/REASONS SIGNATURE
TIME PRE-OP CHECKLIST
1. Consent slip
 Signed
 Refused
 Undecided
2. Emotional/Mental/Spiritual Preparations
 Listens to patients expressing fear and doubt
 Clarifies wrong perception of patient toward
surgery
 Explains the importance of surgical procedure
 Respects religious belief of patient
3. Laboratory results needed
 CBC, platelet, CT, BT, Blood typing
 Urinalysis
 Stool exams
 Blood chemistry
 ECG
 X-ray, ultrasound, CT scan
 Thyroid function test
4. OR slip sent to OR
Received by:

__________________________________
OR manager/OR head nurse

5. CP evaluation/CP clearance
 Poor surgical risk
 Moderate surgical risk
 Low surgical risk
 With recommendations
6. Blood requirements
 FWB, PRBC, FFP, Platelet concentrate
 Available
 Cross matched/antibody screened
 Number of units
7. Materials/medicines ready
8. OR gowns/linens ready
9. Pre-operative health teachings instructed
 Hygiene and physical comfort
 Activities and body mechanics
 Rest and sleep
10. Personal hygiene/physical comfort provided
 Enema
 Douche
 Mouth care
 Bath and personal hygiene
 Shaving of postoperative site per doctor’s order
 Sedatives
 Others___________
11. Sensory preparations
 Nail polish removed
 Shaving of operative site per doctor’s order
 Dentures, hearing aids, eyeglasses, jewelries
removed and kept
12. Fluid and diet properly instructed per doctor’s order
13. Elimination
 Bowel and urinary elimination properly checked
and recorded
14. Pre-operative orders carried out
IVF inserted: Time:
Medicines given:
a. Time:
b. Time:
c. Time:
d. Time:
15. Vital signs: Time:
Temp:
PR:
RR:
BP:
O2 sat%:
16. Medications en route to OR given per doctor’s order
Dosage/Route
a. Time:
b. Time:
c. Time:
d. Time
17. Endorsed to OR/Received by:

_________________________________________
Ward nurse/OR nurse

18. Post-operative bed properly made

19. Necessary materials prepared at bedside
Oxygen bag-valve mask
IV stand nasal cannula
T-piece face mask
Suction machine with catheter