Pediatric Surgery Pre-Operative Checklist
Patient Name
Medical Record Number
Date of Birth
Age
Scheduled Procedure
Date of Surgery
Surgeon
Anesthesiologist
Pre-Operative Checklist
Consent Form Signed
ID Band Applied and Checked
NPO Status Confirmed
Allergies Checked
Pre-Op Vitals Taken
IV Access Established
Pre-Op Medication Given
Labs & Investigations Reviewed
Surgical Site Marked
Immunization Status Checked
Other Considerations
Blood/Blood Products Available (if indicated)
Parent/Guardian Present
Special Needs/Considerations
Comments / Notes
Nurse/Pre-Op Staff Name
Date & Time of Completion