Inpatient Pre Operative Optimization Readiness Checklist
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1Inpatient Pre-Operative Optimization/Readiness Checklist
Place Patient Demographic Label Here
Date of Surgery _________________________
Pager/Number________________________
Unit/Bed ___________
Service_____________________
Surgical Team Pre-operative Checklist
Complete N/A
Comments:
Initials/Date
X
RW 7/1/13
History and Physical in chart?
Cardiac and Lung Assessment documented in chart within 24 hours of planned procedure?
Medication Reconciliation complete and in chart?
Surgical Consent reviewed with patient, signed, and in chart?
NPO after midnight status ordered?
If patient receiving Tube Feeding, hold tube feeds six hours prior to OR start time.
Indicate time for nursing to stop tube feeding on orders.
Site and side marked appropriately if applicable (use provider initials to mark site)?
Skin prep (chlorhexidine wash) ordered if appropriate?
VTE orders complete and in chart?
If patient is on anticoagulant, medication management guidelines referred to for proper
perioperative dosing?
For patients receiving beta-blockers, order continued during peri-operative period and day of
surgery?
Antibiotic order form completed (if peri-operative prophylactic antibiotics are indicated)?
Insulin orders (refer to inpatient glycemic protocol)
Appropriate IV hydration ordered for patients after MN?
Does patient have appropriate IV access (minimal 20 gauge IV)?
Lab grid reviewed on reverse of this form to ensure appropriate labs ordered for patient prior to
surgery (please order needed labs for 2100 on the night prior to surgery)?
Anesthesia Pre-operative Checklist
Complete N/A
Comments:
Initials/Date
X
RW 7/1/13
Anesthesia assessment form complete?
Medications and labs reviewed?
Appropriate orders written (see above and order section of the chart)?
Anesthesia pre-operative nursing order form complete (please file in the Operative section of the
patient chart)?
Is regional block ordered if applicable?
IPD Nursing Pre-operative Checklist
Complete N/A
Comments:
Initials/Date
X
RW 7/1/13
Surgical consent is signed and in chart?
Admission consent is signed and in chart?
Advance Directives are in chart if applicable and available?
Patient identification band is on patient and identification confirmed?
NPO status maintained (please indicate in comment section to the right the time the patient was
made NPO and/or the time tube feeding was stopped)?
IV Issues Call 16-1272
Working IV (minimum 20 gauge if possible)?
Skin prep (chlorhexidine wash) completed if ordered?
Family was notified that patient was sent to the peri-operative area (please indicate in comment
section if notification was made by RN or patient)?
Clothing, electronic devices, jewelry, glasses, hearing aides, dentures, piercings removed?
Pre-operative labs ordered per MD completed (should be drawn at 2100 on the night prior to
surgery)?
If patient takes beta blocker, medication given to patient morning of surgery (noted on MAR)?
Anticoagulants given or held per surgeon order (noted on MAR)?
On-Call Antibiotic sent with patient to OR?
Pre-Operative Area Nursing Checklist
Complete N/A
Comments:
Initials/Date
X
RW 7/1/13
Patient identification band is on patient and identification confirmed?
All paperwork complete and on chart (H& P, Advance Directives, Surgical Consent, Admission
Consent, VTE orders, Med Req.)
Pertinent lab results reviewed?
Hair removal complete (if applicable)?
Please PRINT your name and initial below if you are completing portions of this form:
NOT PART OF MEDICAL RECORDS
Surgeon:_DR. Ron White_Initials:__RW__Date:_7/1/13_Time:________ Anesthesia:_________________Initials:_________Date:_________Time:________
IPD RN:_________________Initials:_______ Date:_________ Time:________
Pre-OP RN:_________________Initials:_________Date:________Time:________
IPD RN:_________________Initials:________Date:_________ Time:________ Circulating RN:_________________Initials:_______Date:________Time:_________
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