Record of Care

All entries are signed, dated, and timed.
Providers must document ID# after signature.
Write legibly.
No prohibited abbreviation in the medical record.
Verbal orders are co-0signed within three calendar days

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:
ASA Classification
Review of medical history, including anesthesia, drug and allergy history
Plan of anesthesia care

Anesthesia Informed Consent

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

Nursing Intra/Post Procedure Note


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
- Correct patient identity
- Correct site
- 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:
-Respiratory function (respiratory, airway patency, oxygen saturation)
-Cardiovascular function (pulse rate and blood pressure)
- Mental status
-Nausea and vomiting
-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:
-Surgeon and assistant names
-Procedure performed
-Description of findings
-Pre-op diagnosis
-Post-op diagnosis
-Estimated blood loss
-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:
-All elements specified for immediate post-op note PLUS:
-Detailed description of procedure
-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.

Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.