Title Page

  • Document No.

  • Audit Title

  • Client / Site

  • Conducted on

  • Prepared by

  • Location
  • Personnel

  • Time out is conducted prior to skin Incision or introduction of scope?

  • All other activities are suspended (except in case of life-threatening emergency) during the time out?

  • During time out the procedure is identified, correct laterality if applicable is identified, and patient consent is verbalized?

  • Surgical Site is marked and visible ( if applicable)?

  • Relevant images properly labeled and displayed?

  • Checked implants are readily available?

  • Verbalized dry time for skin antiseptic has occurred (3 min.)?

  • Antibiotic prophylaxis ordered and started before incision?

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