PRE-OPERATIVE CHECKLIST
Name of patient:
Diagnosis:
Proposed surgical procedure:
Admission date and time: Ward/room:
Covid classification:
Non-Covid
Probable
Confirmed
RT-PCR requested: Yes No Date swabbed:
Triaging of surgeries during COVID-19 pandemic (based on hospital policy):
Emergent, within 24 hours
Urgent, time-sensitive, up to 4 to 8 weeks
Low acquity, maybe delayed up to 12 weeks
A. Admitting ER nurse:
Admitting ward nurse:
Date and time transferred to ward:
B. Resident-in-charge/main surgeon:
Consultant on deck:
Referred
Not referred
C. Surgeon's preference on reserved blood prior to OR:
Yes (Refer to item no. 5 on blood requirements)
No (Surgeon and anesthesiologist should sign for confirmation)
Surgeon: Anesthesiologist:
D. Anesthesiology/resident-in-charge:
Consultant on deck:
Pre-operative Checklist
IST
Age:
Time swabbed:
Pre-operative Checklist (Page 1 of 4)
Please check the appropriate column:
Date/
Comments Yes
time:
Pre-operative checklist
1. Consent slip
>Signed
>Refused
>Undecided
2. Emotional & spiritual preparation
>Listened to patient expressing fear and doubt
>Carified wrong perceptions toward surgery
>Explained importance of surgical procedure
>Showed respect to religious beliefs of patient
Yes
3. Laboratory results needed
>CBC, platelet, CT, BT, blood typing, protime
>Urinalysis
>Stool exam
>Blood chemistry (FBS, BUN, creatinine, sodium, potassium, CBG, uric
acid, lipid profile, protein, SGOT, SGPT)
>ECG
>Xray/ultrasound/CT scan
>Thyroid function test
4. CP evaluation/clearance
IM/pedia resident-in-charge: __________________________________
IM/pedia consultant on duty: __________________________________
RISK STRATIFICATION
>High surgical risk
>Moderate surgical risk
>Low surgical risk
PEDIA EVALUATION:
( ) ASA 1 ( ) ASA 2 ( ) ASA 3 ( ) ASA 4
Recommendations/additional orders:
Date and time referred:
5. Blood requirements
Blood type: ( )
Blood products number of units required:
( ) FWB ( ) PRBC ( ) FFP ( ) Platelet concentrate
( ) Others
Crossmatched & antibody screened: ( ) Yes ( ) No
6. Special equipment/modalities/instruments/supplies:
>
>
>
>
>
7. Checklist completed: If NO, please indicate in the remarks column
pending items to be complied
Pre-opera
Nurse-in-
No Remarks charge's
Signature
Remarks/ Date & time Nurse-in-
No specimen extracted/ charge's
Procedure performed Signature
Pre-operative Checklist (Page 2 of 4)
Date/
OR TRANSIT TIME MONITORING Yes No
time:
8. OR slip sent to OR/uploaded to OR information system
Received by:
__________________________
OR manager/OR charged nurse
Signature over printed name
9. Pre-operative evaluation done by:
__________________________
Anesthesiologist resident-in-charge
Signature over printed name
10. OR Preparations
OR ready/Equipment ready
(according to phone update by the OR team)
__________________________
OR charged nurse
Signature over printed name
Date/ Comments Yes No
time:
11. pre-operative health teachings instructed
>Hygiene & physical comfort
>Activities & body mechanics
>Rest & sleep
12. Personal hygiene/physical comfort provided
>Enema
>Douche
>Mouth care
>Bath and personal hygiene
>Surgical site preparation/shaving according to doctor's order
>Sedatives
>Others:
13. Sensory preparations
>Dentures, hearing aids, eyeglasses, jewelries removed and kept
>Nail polish removed
14. Fluids/diet properly instructed
15. Elimination
>Bowel and urinary elimination properly checked and recorded
Pre-operative Checklist (Page 3 of 4)
Nurse-in-
Remarks charge's
Signature
Nurse-in-
Remarks charge's
Signature
operative Checklist (Page 3 of 4)
Date/
Comments Yes No
time:
16. Pre-operative orders
>IV Fluids started: Time:
>Medications given:
a. Time:
b. Time:
c. Time:
d. Time:
>Blood line established (as necessary)
17. Changed to patient's gown
18. Medications given en route to OR:
Dosage/Route:
a. Time:
b. Time:
19. Latest vital signs:
Temperature:
Blood Pressure:
Heart rate:
Respiratory rate:
20. Patient called for wheeling in
__________________________
OR charged nurse
Signature over printed name
21. Patient at OR table
__________________________
Surgeon
Signature over printed name
22. Patient endorsed to OR/received by:
__________________________
OR charged nurse
Signature over printed name
23. Reason for delay (if applicable):
24. Post-operative bed properly made
25. Necessary materials prepared at bedside:
>Oxygen > Ambubag
>IV stand >Nasal cannula
>Suction machine with catheter
Pre-operative Checklist (Page 1 of 4
Nurse-in-
Remarks charge's
Signature
operative Checklist (Page 1 of 4)
