PRE-OPERATIVE CHECKLIST
Patient Details
Name: _________________________
Age: ______ Sex: ○ M ○ F ○ Other
UHID: _________________________
Ward / Bed: ____________________
Procedure: _____________________
Pre-operative Day Preparation
☐ Pre-operative instructions given to patient/attender in preferred language
☐ Fasting guidelines explained and confirmed
☐ Pre-operative bath/cleaning completed
☐ Part preparation completed
☐ Patient items identified and labelled
☐ Consent forms completed by patient/attender
☐ Blood products arranged (if anticipated)
☐ Special equipment confirmed available
☐ Anaesthesia consultation completed
Day of Surgery – Ward Checklist
☐ Patient identity verified with ID band
☐ Procedure and surgical site verified with patient/attender
☐ Surgeon identity confirmed with family/attender
☐ Attender identity verified
Medical Review
☐ History & physical examination updated (<24 hrs)
☐ Lab results reviewed & acceptable
☐ Imaging studies reviewed & available
☐ Consent forms complete & signed
☐ Allergies verified & marked
☐ Surgical fitness confirmed
Physical Preparation
☐ NPO status confirmed as per guidelines
☐ Vital signs stable
☐ Temperature < 38°C
☐ No signs of acute illness (URI, fever, rash)
☐ Surgical site marked by surgeon (if applicable)
Fasting Guidelines
Solids: ___ hrs before surgery (usually 12 hrs)
Clear liquids: ___ hrs before surgery (usually 8 hrs)
Medications
☐ Pre-medication given as ordered
☐ Chronic medications continued/held per orders
☐ Allergies rechecked & documented
☐ Test dose administered (if required)
Pre-operative Holding Area
Family preparation:
☐ Attender counselled
☐ Comfort measures explained
☐ Expected duration of surgery discussed
☐ Waiting area information provided
☐ Updates during surgery assured
Final verification:
☐ Patient identity re-verified with attender
☐ Procedure & site re-confirmed
☐ Surgeon availability confirmed
☐ Anaesthesia team ready
☐ OR available & prepared
Patient preparation:
☐ Anxiety level assessed
☐ Comfort measures provided
☐ Premedication effect assessed
Equipment & Supplies Checklist
☐ Equipment/supplies arranged as per e-prescription
Antibiotic Prophylaxis
Indicated: Yes / No
Antibiotic: ____________________
Dose: ______ mg/kg
Timing: Within 60 min of incision
☐ Weight-based calculation verified
Isolation Precautions (if indicated)
☐ Standard
☐ Contact
☐ Droplet
Sign-off
Checklist completed by: _____________ Signature: __________ Date/Time: ________
Nurse Supervisor: _________________ Signature: __________ Date/Time: ________
Senior Nurse: _____________________ Signature: __________ Date/Time: ________