NAME: _________________________________________ DATE: _______________________

POST OPERATIVE BED MAKING CHECKLIST PROCEDURE

Criteria 4 3 2 1 Remarks
ASSESSMENT
1. Reviewed doctor’s order; practice institutional guidelines
on post op patient bed preparation
2. Checked the correct patient and level of conciousness
3. Checked for presence of contraptions (IV, Wound
Dressings, Foley Catheter, NGT etc)
PLANNING
4. Identified/stated expected outcomes correctly
5. Gather Supply and materials needed:
 Disposable gloves
 Bottom Sheet, Draw sheet, Top sheet, Blanket
(Optional) Pillow Case.
 Yellow bag (disposal)
6. Strip the used linen & pillow case and placed in the hamper
7. Check that the bed is appropriately positioned near the
room entrance where patient on stretcher will enter.
8. Transfer patient from stretcher to bed
IMPLEMENTATION (Procedure)
9. Strip the bed and properly dispose on yellow bag
10. Place and leave the pillow on the bedside chair.
11. After disinfecting the bed, Apply the bottom linen as for an
unoccupied bed
12. Place a draw sheet on the bed if this is agency practice.
13. Place the top covers (sheet, blanket, and bedspread) on the
bed as you would for an unoccupied bed. Do not tuck them
in, miter the corners, or make a toe pleat
14. Fanfold top sheets from anticipated chest part of the bed to
foot of bed to convert closed bed to open bed.
15. Create at least 2 accordion pleats toward the opposite side
of the bed.
16. Put the pillow case on the pillow properly, set aside.
17. Leave the bed in high position with the side rails down
18. Lock the wheels of the bed if the bed is not to be moved.

EVALUATION
19. Transfer the patient from stretcher to bed safely.
20. Documents that the procedure is done and tolerated.
TOTAL POINTS
 TRANSMUTED GRADE: ___________________________

STUDENT SIGNATURE: ___________________________ DATE: ______________________

CI NAME & SIGNATURE: ___________________________ DATE: _____________________

NAME: _________________________________________ DATE: _______________________

SURGICAL SKIN PREPARATION CHECKLIST: ORTHOPEDIC PREPARATION

Criteria 4 3 2 1 Remarks
ASSESSMENT
1. Reviewed doctor’s order; verify institutional protocol on
 skin prepping, e.g. antiseptic to use.
2. Checked the correct patient.
3. Checked for allergies, time of surgery.
PLANNING
4. Identified/stated expected outcomes correctly
5. Gather equipment needed: Prep Tray
 4 pairs of sterile gloves
 Alcohol-soaked cherries
 Cutasept (Isopropanol + Benzallkonium Chloride)
Spray
5. Check the label of antiseptics: its expiration date, date of
preparation and the name and signature of the surgical staff
who prepared.
6. Check that the patient is appropriately positioned for the
surgical procedure.
7. Checked that the incision site is correctly marked. Remove
dressing/bandages, if necessary.
IMPLEMENTATION (Procedure)
8. Wash your hands using alcohol gel or wash them with soap
and water. Don PPE if appropriate.
9. Apply drip towels immediately below the area to be
prepped.
10. Ask the orderly to put on two sterile gloves to assist in
lifting the affected limb distal to the operating table.
11. Scrub the skin using cherries soaked in betadine cleanser
starting in the site of incision in a circular motion
extending to the peripheries.
12. Apply enough pressure and friction to remove the dirt and
microorganism from skin and pores without abrading the
skin. (Use cotton applicator when cleaning the umbilical
area).
13. Discard the sponge after reaching the periphery. Do not go
back to the center or to the incision site.
14. Repeat the scrub with a different sponge for each stroke
three to five times.
15. Use the sterile towel provided in the prep tray to dry and to
remove excess cleanser on the operative site.
16. Instruct the orderly/auxillary team to remove the first glove
17. Paint the incision site with betadine solution in a circular
manner starting in the incision site and to the peripheries.
18. Remove drip towels with caution so as not to contaminate
the prepped area.
EVALUATION
19. Dispose gloves and wash hands.
20. Documents that the procedure is done. Include the
antiseptic agent used and the technique in application.
TOTAL POINTS

TRANSMUTED GRADE: ___________________________

STUDENT SIGNATURE: ___________________________ DATE: ______________________

CI NAME & SIGNATURE: ___________________________ DATE: _____________________

NAME: _________________________________________ DATE: _______________________

SURGICAL SKIN PREPARATION CHECKLIST: VAGINAL/PERINEAL PREPARATION

Criteria 4 3 2 1 Remarks
ASSESSMENT
 1. Reviewed doctor’s order; verify institutional protocol on
skin prepping, e.g. antiseptic to use.
2. Checked the correct patient.
3. Checked for allergies, time of surgery.
PLANNING
4. Identified/stated expected outcomes correctly
5. Gather equipment needed: Prep Tray
 2 sterile bowl
 sterile gloves
 sterile water for irrigation
 Betadine cleanser
 Betadine solution
 Gauze
 Kelly pad
5. Check the label of antiseptics: its expiration date, date of
preparation and the name and signature of the surgical staff
who prepared.
6. Check that the patient is appropriately positioned for the
surgical procedure.
7. Checked that the incision site is correctly marked. Remove
dressing/bandages, if necessary.
IMPLEMENTATION (Procedure)
8. Wash your hands using alcohol gel or wash them with soap
and water. Don PPE if appropriate.
9. Insert the Kelly pad under the patient’s buttocks and drip
towels.
10. Wash the perineal area with sterile water.
11. Using gauze with betadine cleanser, apply the 7 stroke
technique which includes pubis, vulva, labia, perineum,
anus, and adjacent area, including the inner aspects of
upper third thighs. This must be done twice.
12. Wash the perineal area with sterile water.
13. Using gauze with betadine solution, repeat step no. 11.
14. 14. Rinse with sterile water. Do not blot or wipe off the area .
15. Remove the Kelly pad and drip towels with caution so as
not to contaminate the prepped area.
16. Inspect patient’s back for dryness. Wipe it dry if necessary.
17. Recheck patient’s position.
18. Ensure that the area is dry before draping.
EVALUATION
19. Dispose gloves and wash hands.
20. Document that the procedure is done. Include the
 antiseptic agent used and the technique in application.
TOTAL POINTS

TRANSMUTED GRADE: ___________________________

STUDENT SIGNATURE: ___________________________ DATE: ______________________

CI NAME & SIGNATURE: ___________________________ DATE: _____________________