‘ILOILO DOCTORS’ COLLEGE ‘COLLEGE OF NURSING West Avenue, Molo, Tloilo Cty 5000 Philippines Operating Room Department Pre-Operative Checklists Patient:___ Room No.Ward:, Date: TaatWane Fiat Nae Wide tar 1. Consent slip for operation signed. Yes __. No Witnessed by lame | ital Employee) 7. Operation arranged with O.R. Yess No___ 4. Skin preparation of operative site done by Checked by ree 4, Cleansing bath done by. (Paying attention to a ‘S. Enema if ordered Given by Results recorded Yes Ne ©. On NPO patient (patient instructed i Yes ____ No__ + Time patient last voided? Ne) Foley catheterization done by. Removal of dentures done? Removal of prosthesis done?. ‘Nail polish removal 10. Hair clips removal Jewelles removes Wedding band removed Laboratory results on chart A Xray None Yes No Blood_ None Yes No Others None Yes No Blood serum extracted (for al BZ None Yes No 1A. Pre-op medication, Time Given 4, Yes Ne J eggings on Yes o Undergarment removed, .V cis pm No RER Open gown on, Yes No 18, Vital Signs: TBP PR RR Yes No__— On ieoord Yes No i. Chart signed by Registered Nurse Yes 10 | find the preparation: of the patient satisfactory. OR. Nurse On-Duty | find the preparation of the patient unsatisfactory. Reason at the back. Nurse On-Duty