Preoperative Checklist
Write legibly and do not use abbreviations
Today’s Date:________________________________________________________________________
Patient First Name:_________________________________________________________________ Last Name:___________________________________________________
Identifier 1: _________________________________________________________________________ Identifier 2:__________________________________________________
Surgeon Name: _____________________________________________________________________ Date of Surgery:____________________________________________
Patient Information (please check/circle when completed)
• Patient correctly identified Patient identifier:_________________________________________________________________________
• Procedure to be performed: __________________ Surgical consent form completed
• Copy of living will/advance directives on chart: Yes / No
• Consent includes side: ___ Left ___ Right ___ Bilateral ___ N/A
• Preoperative instructions provided to patient or patient’s legal representative: Yes / No
Medical Documentation (please check when completed)
• History and physical attached Physician’s orders attached
• History and physical identifies side: ___ Left ___ Right ___ Bilateral ___N/A
• Pathology/laboratory studies completed
• Radiologic studies, identify side/site if applicable:________________________________________________________________________________________
• EKG completed
• Other tests completed:____________________________________________________________________________________________________________________
Surgical Information (please check/circle when completed)
• Time of surgery verified Surgical procedure verified
• Surgical site verified Surgical side: ___ Left ___ Right ___ Bilateral ___N/A
• Surgical position verified
• Positioning device required: Yes / No
• Implants/other instrumentation verified If Yes, specify :__________________________________________________________________________
________________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________
Comments:
________________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________
Information taken by Name (please print):___________________________________________________
scheduling staff:
Signature: _____________________________________________________________
Date:________________________________ Time: ___________________________
This form is provided as a sample only and is not meant to be used as is.
patientsafety.pa.gov
