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Mental Status / LOC
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Mental Status / LOC
• • •
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General Checklist
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Primary Language
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Interpreter Required?
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Patient Identity Confirmed?
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Wristband placed on patient?
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Allergy band applied?
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Hair Removed?
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Valuables Collected?
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Body temp within normal range?
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Normothermia Method
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Warming Unit Used?
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Pre-Op Vitals
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Heart Rate
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ECG Rhythm
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Blood Pressure
/
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Respiratory Rate
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SpO2
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Height (inches)
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Weight (lbs)
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Procedure Checklist
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Pre-Admit Questionnaire Reviewed?
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Is Patient NPO?
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Liquids
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Time of last liquid
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Solids
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Time of last solid
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Last Voided
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Time of last void
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Procedure confirmed with patient?
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Consents signed and witnesses?
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MD completed site mark?
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H&P Completed?
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Diagnostic imaging results present?
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Special equipment / implants / rep present?
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Pre-Anesthesia Assessment?
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Nursing Assessment?
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Start IV?
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Started By
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IV Site
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Gauge
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Status
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IV Fluids?
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IV Site Assessment
• • •
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Additional RN Comments
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RN Comments
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RN completing Pre-Op Checklist
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