• Conducted on

  • Unit Location

  • Document No.

  • MR No.

  • Surgeon/Proceduralist
  • Anesthesia Provider

  • Staff Involved with Tracer

  • Type of Anesthesia

  • Procedure Name

  • Patient Status: In-patient or Out-patient

  • Admit Service

  • Pre-documentation Identified: Yes or No

  • If yes, type of pre-documentation evident in the chart: H&P Update Note, Immediate Post-Op Note or Other

  • Prepared by

Record of Care

  • All entries are signed, dated, and timed.<br>Providers must document ID# after signature.<br>Write legibly.<br>No prohibited abbreviation in the medical record.<br>Verbal orders are co-0signed within three calendar days<br><br> Include forms that are of clinical nature only (advance directive form, anesthesia pre-assessment, etc.) Do NOT include informed consents in this column (addressed later in the tool).


  • H&P completed no more than 30 days before or 24 hours after patient admission.

H&P Update Note

  • H&P Update Note by JHH Provider within 24 hours after admission and before surgery

Pre-op Checklist

  • Pre-procedure checklist present?

Procedural Informed Consent

  • Procedure informed consent completed, signed, witnessed, dated and timed before procedure

  • Procedural informed consent clearly documents the risks and benefits of the alternatives to the surgery

Pre-Anesthesia Assessment

  • Pre-anesthesia assessment contains following elements:<br>Heart<br>Lungs<br>Airway<br>ASA Classification<br>Review of medical history, including anesthesia, drug and allergy history<br>Plan of anesthesia care

Anesthesia Informed Consent

  • Anesthesia informed consent completed, signed, witnessed, dated and timed before procedure

Nursing Intra/Post Procedure Note

  • Intra-procedure <br>Post-Procedure<br>

Site Marking

  • Is the procedure site marked with the provider's initial?

  • Is site marked before the patient is moved to the procedure location?

Time-Out/Universal Protocol

  • Anesthesia Time-Out is documented prior to induction.

  • Time out is documented<br>- Correct patient identity<br>- Correct site<br>- Procedure to be done

  • Is the time-out conducted prior to starting procedure?

Medication/Solution Labeling and Storage

  • If not immediately administered, all medications are labeled with the medication name, strength, amount and diluent/volume (if not apparent from the container,

  • Propofol is clearly labeled with date and time medication was prepared in syringe. Note: Propofol must be administered within 6 hrs of preparation.

  • Multi-dose vials that are opened in immediate care areas (OR, patient or clinic room, or procedure room) are treated as single-use vial (used for only one patient) and discarded at the end of the procedure.

  • Nonscheduled medications are secured in a locked drawer, cart or Pyxis when the area is not under direct observation by authorized staff.

Post-Anesthesia Eval

  • Is post-anesthesia evaluation documentation present within 48 hours of the procedure?

  • Required elements documented no more than 48 hours post-procedure:<br>-Respiratory function (respiratory, airway patency, oxygen saturation)<br>-Cardiovascular function (pulse rate and blood pressure)<br>- Mental status<br>-Temperature<br>-Pain<br>-Nausea and vomiting<br>-Post- operative hydration

Immediate Post-Op Note

  • Is the immediate post-op note/brief op note present immediately after procedure and before transfer to PACU or sending unit?

  • Required elements documented immediately after procedure and before transfer to PACU or sending unit:<br>-Surgeon and assistant names<br>-Procedure performed<br>-Description of findings<br>-Pre-op diagnosis<br>-Post-op diagnosis<br>-Estimated blood loss<br>-Specimens removed

Detailed Post-Op Note

  • Is the detailed post-op note present and finalized within 7 days of post-procedure?

  • Required elements documented within 7 days post-procedure:<br>-All elements specified for immediate post-op note PLUS:<br>-Detailed description of procedure<br>-Clinical stage of tumor as appropriate

Additional Documentation

  • Home medication list completed

  • Discharge instructions documented

  • Home medication list updated, as appropriate

  • Advance Directives (AD) documentation completed

Additional Areas:

  • Laryngoscope blades are stored individually and are packaged in a clear bag or peel pack.

  • Laryngoscope blades removed from the bag or peel pack, available for use on an anesthesia cart or in a procedure room, are covered with a blue towel prior to the scheduled procedure. Note: Only one laryngoscope maybe placed on cart in preparation of immediate case and must be covered.

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. You should independently determine whether the template is suitable for your circumstances.