Free Professional Treatment Checklist Template
Professional Treatment Checklist
Patient Name: Edgar Spencer
Procedure: Appendectomy
Date of Surgery: May 15, 2050
Procedure Code: 49320
Pre-Operative Checklist
|
Task |
Status |
Notes |
|---|---|---|
|
Verify patient ID and medical history |
|
Confirm allergies and medications |
|
Consent form signed |
|
Ensure form is complete |
|
Sterilization of equipment |
|
Check sterilization logs |
|
Confirm anesthesia plan |
|
Review patient’s anesthesia risk |
|
Pre-surgery vital signs taken |
|
Blood pressure, heart rate |
Surgical Procedure Checklist
|
Task |
Status |
Notes |
|---|---|---|
|
Confirm surgical site marked |
|
Double-check with patient |
|
Prepare surgical tools |
|
Verify all tools required |
|
Anesthesia administered |
|
Confirm dosage and administration |
|
Sterile drapes applied |
|
Ensure sterile environment |
|
Begin procedure |
|
Start surgery |
Post-Operative Checklist
|
Task |
Status |
Notes |
|---|---|---|
|
Post-operative vitals monitored |
|
Hourly monitoring for 4 hours |
|
Pain management discussed |
|
Administer prescribed pain relief |
|
Recovery room preparation |
|
Ensure room is equipped |
|
Post-op instructions given to patient |
|
Review recovery steps with patient |
|
Schedule follow-up appointment |
|
Set for June 5, 2050 |
Patient Information
-
Patient's Name: Edgar Spencer
-
Patient's Email: edgar@you.mail
-
Patient's Phone Number: 222 555 7777
Hospital/Clinic Information
-
Hospital/Clinic Name: [YOUR COMPANY NAME]
-
Address: [YOUR COMPANY ADDRESS]
-
Phone Number: [YOUR COMPANY NUMBER]
-
Email: [YOUR COMPANY EMAIL]
Next Steps
-
Schedule Appointment: If this checklist is part of your treatment process, please schedule your next appointment as soon as possible.
-
Contact Us: If you have any questions about your procedure or post-operative care, reach out to us at [YOUR COMPANY EMAIL].
