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PRE-OP ADMIT RECORD
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Are you having pain? Controlled?
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Able to Cough & Deep Breath?
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Any trouble swallowing?
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Able to ambulate?
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Pre-Op Admit Notes
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ASSESSMENT
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Mental Status
• • •
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Speech
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Behaviour
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Extremities: Color
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Extremities: Temp
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Extremities: Cap Refill
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Vision
• • •
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Skin
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Pupils
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Hearing
• • •
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Respiratory
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Cardiac Rhythm
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GI: Abdomen
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Cough
• • •
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Edema?
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If Yes, edema location
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Checklist
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Consents Signed
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States scheduled procedure
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Pre-Anesthesia record complete
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TEDS / SCDs BLE
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Jewelry Removed
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Unable to remove jewelry, PT aware of risks
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Dentures removed
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ID Band
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Food Intake @
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Fluid intake @
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Glasses / Contacts removed
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Voided Today
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Clipped Site: Nipple to Umbilicus
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Prosthetic implants
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Prosthetic implants:
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HTN / Beta Blocker
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HTN / Beta Blocker Time
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Blood Thinners
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Blood Thinners Time
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Pre-Op Medication
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Scopolamine Patch - Right Ear
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Time given
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RN
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Toradol 30mg - IV
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Time given
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RN
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Famotidine 20mg (PRN) IV
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Time given
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RN
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Versed 1-2mg (PRN) - IV
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Time given
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RN
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Albuterol Breathing Treatment (PRN) - ORAL
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Time given
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RN
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IV
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Guage
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0.9% NS
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Ultrasound Guided
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Site
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Attempts
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RN
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Aseptic Technique
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Signatures
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Admitting RN
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Time
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OR RN
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Time
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