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PATIENT’S IDENTIFICATION

PRE-OPERATIVE CHECK LIST


CHECK YES, NO OR N/A FOR ITEMS 1 TO 4 AND
CHECK YES, NO OR N/A FOR ITEMS 1 TO 20 AND RECORD INITIALS RECORD INITIALS
YES NO N/A INITIALS YES NO N/A INITIALS
1. ID bands applied
2. 2 Blood bands applied #_____________ 1. Wearing ID Band that
Autologous/donor directed blood avail are legible
3. Blood consent signed and witnessed and 2. Blood bank two ID
on chart Bands in place
4. If no blood consent, blood refusal form 3. Consent Signed and
signed and on chart Witnessed
5. Consent signed and witnessed and on 4. Laterality on the
chart Consent form is
6. Laterality identified on the consent form. consistent with:
Surgery will be on the (circle one) - the OR schedule
Right Left Bilateral Midline - patient response
- the pre-op checklist
7. Laterality on the consent form is
consistent with the patient's response 5. Allergies
8. Allergies No known allergies ____________________________________________
Latex ____________________________________________
9. Last Food and Drink since___________ 6. Time Arrived in Pre-op Holding_________________
10.Thromboprophylaxis 7. Chart Checked for Completeness_______________
Risk Status Low Med High 8. IV Fluids Amount _____________________
11. Pre-op medication
Time:___________________________ Signature_____________ Initials_________________
Medication_______________________
12. Vital Signs NOTE_______________________________________
BP______________ P_____________ ____________________________________________
Temp ___________ RR____________ ____________________________________________
13. Voided Time___________________
14. Height__________ Weight__________ STATEMENT OF PATIENT COMPLIANCE
15. Patient personal belongings: I AM AWARE OF THE DANGER TO ME OF FOOD OR
Dentures_________________________ LIQUID (INCLUDING WATER, COFFEE, OR TEA) IN
Corrective lenses __________________ MY STOMACH DURING ANESTHESIA AND I
Hearing aid ______________________
Jewelry _________________________ CERTIFY THAT I HAVE HAD NOTHING TO EAT OR
Clothing or other___________________ DRINK SINCE_______________________________
Disposition EXCEPTIONS: ______________________________
□ Admission Services I CERTIFY THAT I HAVE AN ESCORT HOME
□ Family Member (____________) WHOSE NAME IS: ___________________________
□ Remains w/Patient PATIENT: __________________________________
□ Other_____________________ WITNESS: __________________ DATE: _________
16. Nail Polish Removed
17. Isolation *See Isolation Guidelines on Isolation Precautions Guidelines
May go to Pre-op May go to PACU
opposite side. Type________________ Airborne No No
18. Most recent investigations/results: Respiratory (Droplet) No No
X-rays, Scans, Bloods, BM etc. Strict No No
19. Medical record with chart Contact No Yes (in isolation room)
Special Handling Yes Yes
20. Addressograph plate on chart Protective
(CJD) No No

Signature______________________ Initials________________________

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