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1. IV IN PLACE AND BOLUS 1 LITER (FIRST ORDER OF BUSINESS)
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Nurse
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Front Desk Staff
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RN
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2. CONFIRM PHOTOGRAPHS – IF NOT ATTAIN IMMEDIATELY
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Nurse
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Front Desk Staff
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RN
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3. S1-S6 SIGNED BY SURGEON
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Nurse
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Front Desk Staff
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RN
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4. A1-A4 SIGNED BY ANESTHESIOLOGIST
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Nurse
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Front Desk Staff
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RN
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5. P1-P14 SIGNED BY PATIENT
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Nurse
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Front Desk Staff
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RN
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6. HISTORY & PHYSICAL WITHIN 30 DAYS (UPDATED WITHIN 24 HOURS OF SURGERY)
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Nurse
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Front Desk Staff
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RN
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FO
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H&P MUST CLEARLY STATE WHY THE PATIENT IS HAVING SURGERY AND THEY STILL HAVE SYMPTOMS TODAY FOR ALL INSURANCE CASES
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7. BREAST CASES >40 MAMMOGRAM
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Nurse
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Front Desk Staff
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RN
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Mammogram Document
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8. AGE >40 EKG
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Nurse
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Front Desk Staff
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RN
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EKG Lab
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9. BLOOD WORK PER PROTOCOL
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Nurse
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Front Desk Staff
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FO
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RN
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Blood Work
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10. URINE HCG ALL FEMALES REGARDLESS OF TUBAL LIGATION, OLDER AGE OR HYSTERECTOMY (COMMON SENSE MAY INDICATE OTHERWISE BUT VERY
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Nurse
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Front Desk Staff
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RN
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11. QUOTE SHEET, MATCHES SCHEDULING FORM, SCHEDULING FORM SIGNED BY MOJI AND SURGEON
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Nurse
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Front Desk Staff
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RN
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FO
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12. EMERGENCY CONTACT INFORMATION AVAILABLE
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Nurse
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Front Desk Staff
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RN
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13. INSURANCE INFORMATION, DRIVERS LICENSE IN FILE
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Nurse
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Front Desk Staff
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RN
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14. ALLERGY STICKER COMPLETED ON FRONT OF CHART
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Nurse
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Front Desk Staff
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RN
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Comments
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Name of Person Completing Checklist
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Date/Time
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Nurse Verifying Completion
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Date/Time
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