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Preop Checklist

The document is a pre-operative checklist for a patient undergoing surgery. It lists the patient's name, age, sex, diagnosis, proposed operation, and anesthesia details. It then has a table to check that various pre-op tasks are completed, including obtaining consent, laboratory tests, emotional preparation, notifying the OR, evaluating surgical risk, preparing blood if needed, equipment and medications. It also checks that the patient received pre-op instructions, hygiene, elimination, fluids/diet, vital signs, medications and was endorsed to the OR. Post-op preparations like an oxygen setup are also listed.

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Jan Federick Bantay
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9K views2 pages

Preop Checklist

The document is a pre-operative checklist for a patient undergoing surgery. It lists the patient's name, age, sex, diagnosis, proposed operation, and anesthesia details. It then has a table to check that various pre-op tasks are completed, including obtaining consent, laboratory tests, emotional preparation, notifying the OR, evaluating surgical risk, preparing blood if needed, equipment and medications. It also checks that the patient received pre-op instructions, hygiene, elimination, fluids/diet, vital signs, medications and was endorsed to the OR. Post-op preparations like an oxygen setup are also listed.

Uploaded by

Jan Federick Bantay
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
  • Pre-Operative Checklist

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

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