Hand Surgery Procedural Checklist

Patient Information

Patient Name
Date of Birth
Medical Record #
Date of Surgery
Surgeon
Procedure

Preoperative

Consent form signed Site marked & verified Allergies reviewed Equipment/supplies checked Imaging available Antibiotics administered

Intraoperative

Time-out performed Instrument count correct Tourniquet applied if necessary Hemostasis achieved Specimens labeled

Postoperative

Instrument/sponge count correct Dressing applied Post-op imaging as indicated Postop instructions given Disposition arranged

Comments / Notes