OSPITAL NG MAKATI

Sampaguita corner Gumamela Sts., Brgy. Pembo, Makati City

Tel.# 882-6316 to 36

SURGIC
A LSAF
E T
YCHE
C K
LIST
NAME OF PATIENT: ___________________________________
_______ AGE: ____ SEX: M F HOSPITAL NO.: _______________ IN-PATIENT
OUT-PATIENT
SCHEDULE PROCEDURE:
______________________________________________________________________________________________________________
PRIOR TO INDUCTION OF ANAESTHESIA PRIOR TO SKIN INCISION
BEFORE PATIENT LEAVES OR
TIME OUT
SIGN
SIGNOUTIN
Confirm all team members have introduced
Nurses
Patientverbally
Confirmed
confirms with the
themselves by name & role
team:
• Identify Surgeon, anaesthesia professional and
• Site
nurse
• The name of the procedure
• Procedure
recorded verbally confirm
• Consent
Site marked • Patient
• That • Site Surgeon:
• Yesinstrument, sponge and
• Procedure _________________________________
• needle
Not applicable
count is correct • Position _________________ Anaesthesiologist:
Anaesthesia safety check
• Yes
completed Anticipated critical events __________________________________
Pulse•Oximeter
Not applicable
on a patient and • Surgeon reviews: What are the critical _________________
functioning or Name
Name
Signature
Signature
•Does
How a the specimen
patient have:as labeled unexpected steps, operative duration,
(including
Known patient name)
Allergy: anticipated blood loss?_________________ Nurse:
• No • Anaesthesia team reviews: Are there __________________________________
• Whether there are any equipment
• Yes ___________________ any _________________
problems
Difficult to be aspiration
airway/ address risk patient- specific concerns? Name
• No ______________ Signature
• Surgeons,
• Yes, andAnaesthesia
equipment assistance • Nursing team reviews: Has sterility TQM 10/2010

Professional been
• available
and Nurse review the particular confirmed? Are there equipment issues
Risk of >500cc blood loss (> 7cc/ kg
concerns for recovery and or
in
management of this patient? any concerns?
children)?
_________ Antibiotic prophylaxis given within the last
• No
__________________________________ 60 minutes?
• Yes, And IV Access & fluids
• Yes ______________________
planned
• not applicable
Essential imaging displayed?
• Yes _____________________
• Not applicable
• Other checks