Pre-Operative Nursing Checklist
Name
First Name
Last Name
Date of Birth
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Month
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Day
Year
Date
Sex
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Male
Female
Hospital No:
Proposed Surgery
Blood Group
Zone
Requirements Checklist
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Yes
No
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Informed consent has been taken and the patient consent form has been signed?
Patient has been assessed by Anaesthesiologist?
Surgical site has been marked by a surgeon?
Pre-medication was prescribed?
Has pre-medication been given?
Any reaction after pre-medication was given?
Was blood or a blood product prescribed?
If the answer to the above question is yes, is blood available?
If yes, then has the patient accepted to receive blood?
If no, then has the patient stated this?
Are the Patient's laboratory results available?
Has the patient been appropriately starved?
Has the patient been properly shaved?
Is the patient properly dressed in the operating theatre?
Have the patient's vital signs been checked and documented?
All pre-operative requests e.g. drugs, fluid, instruments, drapes are available?
Does the patient have dentures?
If the patient has dentures, have they been removed?
Have the patient's jewelries' been totally removed?
Urethral catheter has been successfully inserted (when necessary)
Is the patient above the age of 40?
If yes, then has an ECG been performed?
Have the results been documented in the EMR?
Surgeon has reviewed results and patient has been confirmed to be fit for surgery?
Title
Name
First Name
Last Name
Signature
Date
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Month
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Day
Year
Date
Perioperative/Theatre Nurse
First Name
Last Name
Signature
Date
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Month
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Day
Year
Date
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