Ambulatory Surgery Center Pre-Operative Checklist
Patient Name
Date of Birth
Medical Record Number
Surgery Date
Surgery Time
Surgeon
Procedure
Pre-Operative Checklist
Patient identification confirmed
Consent form signed and on chart
History and physical on chart
Baseline vital signs taken
Allergies reviewed
NPO status verified
Home medications reviewed
IV started
Lab results reviewed
Surgical site marked
Pre-op orders implemented
Additional Notes
Pre-op Nurse Name
Date