Title Page

  • Document No.

  • Audit Title

  • Client / Site

  • Conducted on

  • Prepared by

  • Location
  • Personnel

  • Sponges are separated and counted individually.

  • Sterile field is kept organized to identify location(s) of counted items.

  • Count is initiated in a timely manner: prior to incision at start of case.

  • Count is initiated in a timely manner: when wound closure begins.

  • Count is initiated in a timely manner: when skin closure begins -prior to dressing or skin adhesive.

  • Instrument counts are completed as appropriate (with open abdominal or thoracic wounds). The final instrument count should not be considered complete until the instruments used in closing the wound (e.g. malleable, needle holders, scissors) are removed from the wound and returned to the scrub.”

  • The dry erase count board is referred to during case and/or during counts.

  • If count is interrupted, the count is resumed, re-counting the item currently being counted.

  • Items are counted with circulator and scrub participating visually and verbally.

  • Hand off report to relief scrub includes a full count of all available items.

  • Counts are completed starting at field, then to mayo stand, to back table, and off field.

  • Sharps are placed on needle magnet or into foam needle mat for counting without additional handling to avoid injury.

  • Scrub person speaks up when a discrepancy exists.

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. Any ratings or scores displayed in our Public Library have not been verified by SafetyCulture for accuracy. Users of our platform may provide a rating or score that is incorrect or misleading. You should independently determine whether the template is suitable for your circumstances. You can use our Public Library to search based on criteria such as industry and subject matter. Search results are based on their relevance to your search and other criteria. We may feature checklists based on subject matters we think may be of interest to our customers.