Outpatient Procedure Pre-Operative Checklist
Patient Information
Patient Name
Date of Birth
MRN
Procedure
Surgeon
Date of Procedure
Scheduled Time
Pre-Operative Checklist
Item
Yes
No
N/A
Comments
Consent signed
Allergies verified
Site/side marked
NPO status confirmed
Labs/diagnostics reviewed
Vital signs taken
Pre-op meds administered
IV started
Notes / Additional Instructions
Pre-op Nurse Signature
Date