Preoperative Checklist

Purpose: This checklist is intended to ensure that all necessary assessments, consents, and preparations are completed prior to surgery. Use this document to review and confirm patient readiness before proceeding with operative procedures.

Patient Information

• Full Name: {fullName}
• Patient ID: {patientId}
• Date of Birth: {dob}
• Age: {age}
• Procedure Scheduled: {procedureName}
• Date of Surgery: {surgeryDate}

Health Status & Medical History

• Allergies: {allergies}
• Current Medications: {currentMedications}
• Past Surgeries: {pastSurgeries}
• Pre-existing Conditions: {preExistingConditions}
• Fasting Confirmed: {fastingStatus}

Diagnostic Tests & Exams

{#tests}

• {testName}: {testResult}

{/tests}

Consent & Legal Forms

• Surgical Consent Signed: {surgicalConsent}
• Anesthesia Consent Signed: {anesthesiaConsent}

{#insuranceStatus}

Note: Insurance Verified

{/insuranceStatus}

{^insuranceStatus}

Note: Patient has no verified insurance. Proceed according to self-pay protocol.

{/insuranceStatus}

Preoperative Instructions Provided

{#instructions}

1. {instruction}

{/instructions}

Preoperative Checklist Sign-Off

Final Confirmation

• Nursing Review Completed: {nursingReview}
• Surgeon Review Completed: {surgeonReview}
• Patient Identity Verified: {identityCheck}
• Surgical Site Marked: {siteMarked}

This checklist must be reviewed and signed off before proceeding to the operating room.