Audit

Informed Consent and Patient Education

Is there a completed procedural informed consent?

Is there documentation of patient education?

History and Physical

Does the H&P document: Physical exam of body system relevant to procedure?

Does the H&P document: Review of relevant laboratory/diagnostic data?

Does the H&P document: Patient history?

Does the H&P document: Diagnosis?

Does the H&P document: Plan of care?

If the H&P was completed >24 hours prior to procedure, is there an H&P update note completed within 24 hours prior to procedure?

Anesthesia Sedation Assessment

Pre-anesthesia sedation assessment is completed- heart, lungs, airway, and ASA classification?

Post-anesthesia evaluation documented?

Immediate Post-OP note/Post Procedure Note

Does post-op note address all 6 required elements: 1) Surgeon and assistant(s) names, 2) procedure, 3) findings, 4) post-op diagnosis 5) estimated blood loss, 6) specimens. ( must be written before transfer to PACU or sending unit)

Pre-Procedure Verification Process

When the patient is in the Pre-procedure area, is a standardized list used to review and verify that the following items are available and accurately match the patient?
1) Patient identity, procedure & side/site verified.
2) Relevant documentation (H&P, nsg assessment, Pre- anesthesia assess)
3) Accurately completed and signed/dated/timed procedure consent form.
4) Correct and properly labeled diagnostic and radiology test results
5) Any required blood products, implants, devices or special equipment available

Site Marking

Is the procedure site marked with the provider's initials?

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

Time Out

Is time-out conducted prior to starting procedure?

Does the time-out have the following characteristics:
1) Involves the immediate members of the procedure team including the proceduralist(s)- Can be the fellow, the anesthesia providers, the circulating nurse, the OR technician, and other participants as appropriate for the procedure, who will be participating in the procedure at its inception.
2) Involves interactive verbal communication between all team members.

does the time-out address all of the following:
1) Correct pt identification
2) Confirmation that correct site & side are marked
3) An accurate procedural consent form
4) Agreement on procedure(s) to be done
5) Correct patient position
6) Site mark visible after prep and draping
7) Resolution of any conflicts in information
8) Relevant images and results are properly labeled and appropriately displayed
9) Need to administer antibiotics or fluids for irrigation purposes
10) Safety precautions based on pt history and/or medication use

Was the time-out documented?

NPSG: Medication Labeling

Are empty syringes and/or containers labeled immediately after filling?

Do labels include:
1) medication name
2) Strength
3) preparation date
4) amount (if not apparent from container)

Documentation

Every signature is dated and timed

Home medication list completed

Discharge instructions documented

Home medication list updated as appropriate

Advance directives documentation completed

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.