Informed consent signed and on chartConsent matches scheduled procedurePatient verbally confirms procedureSite marked by provider (if applicable)Site marking verified by nurse

Pre-Procedure Assessment

Allergies Verified

NPO Status

Last Oral Intake

Pregnancy Test

Pre-Procedure Checklist

ID band verified (2 identifiers)H&P on chart (within 30 days)Blood type and screen (if applicable)Anticoagulant held per protocolJewelry/piercings removedDentures/hearing aids removedPatient changed into gownPre-op antibiotics given (if ordered)IV access patentPre-op vitals documented

Blood Products

Status

Time-Out

Time-out performed with procedure team

Notes

Additional Notes

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PRE-PROCEDURE VERIFICATION PROCEDURE: [Procedure]. Scheduled: [Time]. Provider: [Provider]. Location: OR. CONSENT: No items documented. ASSESSMENT: Allergies: Not verified. NPO: NPO since midnight. Last PO: [Time]. Pregnancy: N/A. CHECKLIST: No items documented. BLOOD PRODUCTS: Not anticipated. TIME-OUT: Not documented.

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