Ophthalmic Surgery Pre-Operative Checklist
Patient Name
Patient ID / MRN
Date of Surgery
Time of Surgery
Surgeon's Name
Eye to be Operated
Right
Left
Both
Scheduled Procedure
PRE-OPERATIVE CHECKLIST
Consent Form Signed & Verified
Correct Patient Identification
Correct Procedure & Site Confirmed
Pre-Op Assessment Completed
Vital Signs Checked
Allergies Checked
NPO Status Verified
Surgical Eye Marked
Patient Informed of Risks/Benefits
Pre-Op Eye Drops Instilled
Relevant Investigations Available
IOL/Implants Ready (if required)
Anesthetist Assessment (if required)
Surgical Safety Checklist Initiated
Comments / Special Instructions
Pre-Op Nurse Name / Signature
Date