Free Pre-Surgery Checklist Template
Pre-Surgery Checklist
Patient Information
|
Patient Name |
Garfield Williams |
|---|---|
|
Patient ID |
123456 |
|
Date of Birth |
January 01, 1970 |
|
Surgery Date |
May 15, 2050 |
|
Surgery Type |
Gallbladder Removal |
Pre-Surgery Instructions
-
Confirm fasting status: Ensure patient has fasted for at least 8 hours before surgery.
-
Medications review: Verify patient has stopped taking blood thinners as per doctor's instructions.
-
Confirm laboratory results: Ensure blood tests are completed and reviewed (e.g., CBC, liver function).
-
Pre-operative imaging: Confirm that necessary scans (e.g., ultrasound, X-ray) are completed and reviewed.
-
Consent signed: Confirm patient has signed all required consent forms.
Equipment and Supplies Readiness
|
Item |
Status |
Notes |
|---|---|---|
|
Surgical instruments |
|
Sterilized and packed |
|
Anesthesia machine |
|
Function checked |
|
Surgical drapes |
|
Sufficient quantity |
|
IV fluids |
|
Prepared |
|
Sterile gloves and gowns |
|
Packed |
Surgical Team Preparedness
-
Surgeon confirmed: Dr. [YOUR NAME] will perform the procedure.
-
Anesthesia review: Anesthesiologist confirmed and anesthesia plan discussed.
-
Nursing staff informed: All staff assigned to the surgery are briefed on roles and patient information.
-
Surgical site marked: Verify correct site marking on the patient.
-
Emergency protocol reviewed: All emergency procedures reviewed with the team.
Post-Operative Care Plan
|
Task |
Responsible Party |
Date |
|---|---|---|
|
Recovery room readiness |
Nursing team |
May 15, 2050 |
|
Pain management plan |
Anesthesiologist |
May 15, 2050 |
|
Follow-up appointment |
[YOUR NAME] |
May 17, 2050 |
|
Discharge instructions |
Nurse |
May 16, 2050 |
|
Prescription filled |
Pharmacy |
May 15, 2050 |
Contact Information
[YOUR COMPANY NAME]
[YOUR COMPANY ADDRESS]
[YOUR COMPANY EMAIL]
[YOUR COMPANY NUMBER]
Please ensure that all items on this checklist are completed to ensure the smooth and safe conduct of the surgery. If you have any questions or need further clarification, feel free to contact us at [YOUR COMPANY EMAIL] or [YOUR COMPANY NUMBER].
