PRE-OPERATIVE CHECKLIST

NAME: Mrs. MB HOSPITAL NUMBER: LNU

AGE/
SEX: 53 yrs old- Female WARD/ROOM:
NO ITEMS REMARKS
YES
  Identified
  1. Identification band in place correctly using 2
identifiers
  No known drug
  2. Drug sensitivity marked on chart cover
sensitivity
  Informed
consent was
  3. Operative permit signed obtained with
signature of the
patient
    4. Operative site prepared  Left transtibial
   Blood type B+
(how many
  5. Blood available for transfusion
blood bags
available)
  RBC: 4.92
million cells/mcL
HgB: 13.5 g/dL
HCT: 40.4 %
  6. Blood report on chart
WBC: 9,600
cells/mcL
Platelet:
325,000/mcL
  7. Other laboratory resuls on chart (Chemistry,  Electrolyte
 
U/A, F/A) imbalances
   Should be
included
1. Limb
involved
  8. X-ray report on chart
2. Chest x-
ray
Films attached
to the chart
   Identify specific
  9. Imaging report on chart (CT Scan, MRI, UTZ)
diagnostic test
    10. Doctor's order on chart  Carried out-

    11. Nursing notes on chart  Completed

   Attached to the
  12. Preoperative TPR charted
chart
  [ ]VOID [ ] CATHETERIZED  Choose only
one
 
Properly
anchored
    13. Diet and fluids withheld  

    NPO at: 10pm- 07/02/2022  

    14. Make up removed  
  The patient has
  15. Dentures removed
no dentures
  The patient has
no contact
  16. Contact lenses removed
lenses/correctiv
e glasses
   Wedding ring
  17. Jewelry removed removed
c/o relative
    18. Oral and body hygiene completed  
   Procedure is
  19. Preoperative education given clear to the
patient

CP Cleared by: Name and Signature of NOD

DR. MARC LOUISE SARMAC

FELIX JOHN MICU JR. R.N
SPECIAL PRECAUTIONS: TYPE I DIABETIC, HYPERTENSIVE & CATARACTS IN BOTH EYES
Hemoglocuse test monitoring every 4 hours

Weight: 65 kg Latest VS: 130/90 mm/Hg

RR: 15 C/M
PR: 90 BPM
TEMP: 37.3OC
Sp02 92%