Ambulatory Surgery Pre-Operative Checklist
Comprehensive pre-operative verification for ambulatory/outpatient surgery including patient identification, consent, NPO status, and safety checks.
- Industry: Healthcare
- Frequency: Every surgical case
- Estimated Time: 10-15 minutes
- Role: Preop Nurse
- Total Items: 51
- Compliance: CMS ASC CoP 42 CFR 416, Joint Commission Universal Protocol, AORN Guidelines
Patient Identification
Verify patient identity
- Two patient identifiers verified?
- Patient wristband applied and accurate?
- Allergy band applied (if applicable)?
Consent Verification
Surgical consent
- Informed consent signed?
- Consent matches scheduled procedure?
- Consent properly witnessed?
- Anesthesia consent signed?
Pre-Operative Assessment
Patient readiness
- NPO status verified?
- Vital signs within acceptable limits?
- H&P current (within 30 days)?
- Required labs reviewed?
- Home medications reviewed?
Surgical Site Marking
Universal Protocol compliance
- Surgical site marked by surgeon?
- Patient involved in marking process?
- Marking will be visible after prep/drape?
Patient Preparation
Physical preparation
- Patient in appropriate attire?
- Jewelry and valuables secured?
- Dentures/prosthetics noted?
- IV access established?
- Pre-op medications given?
Safety Verification
Final safety checks
- Fall risk assessed?
- Responsible adult escort confirmed?
- Transportation home arranged?
- Emergency contact number verified?
Pre-Assessment Information
Initial assessment documentation and patient/facility identification
- Assessor Name / Credentials
- Assessment Date
- Department / Unit
- Assessment Type (Routine/Annual/Complaint)
- Previous assessment findings reviewed?
Infection Prevention & Control
Verify infection control practices per CDC and Joint Commission standards
- Hand hygiene compliance observed?
- Appropriate PPE available and properly used?
- Isolation precautions properly implemented?
- Sharps containers available and not overfilled?
- High-touch surfaces properly disinfected?
Patient Safety & Identification
Verify patient safety protocols and identification procedures
- Two patient identifiers used before procedures?
- Fall risk assessment completed?
- Call light within patient reach?
- Bed in lowest position with brakes locked?
Medication Safety & Management
Verify medication handling and administration practices
- Medications stored securely and at proper temperature?
- Controlled substances properly secured and counted?
- No expired medications in stock?
- High-alert medications properly labeled?
Environment of Care & Safety
Verify facility environment meets safety standards
- Fire exits clear and unobstructed?
- Emergency equipment functional and accessible?
- Spill kits available and stocked?
- Electrical cords and outlets in safe condition?
Documentation & Regulatory Compliance
Complete assessment documentation and ensure regulatory compliance
- All findings documented with evidence?
- Corrective actions assigned with timeline?
- Staff education provided on identified issues?
- Assessor Signature
- Additional Observations
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Why Use This Ambulatory Surgery Pre-Operative Checklist?
This ambulatory surgery pre-operative checklist helps healthcare teams maintain compliance and operational excellence. Designed for preop nurse professionals, this checklist covers 51 critical inspection points across 12 sections. Recommended frequency: every surgical case.
Ensures compliance with CMS ASC CoP 42 CFR 416, Joint Commission Universal Protocol, AORN Guidelines. Regulatory-aligned for audit readiness and inspection documentation.
Frequently Asked Questions
What does the Ambulatory Surgery Pre-Operative Checklist cover?
This checklist covers 51 inspection items across 12 sections: Patient Identification, Consent Verification, Pre-Operative Assessment, Surgical Site Marking, Patient Preparation, Safety Verification, Pre-Assessment Information, Infection Prevention & Control, Patient Safety & Identification, Medication Safety & Management, Environment of Care & Safety, Documentation & Regulatory Compliance. It is designed for healthcare operations and compliance.
How often should this checklist be completed?
This checklist should be completed every surgical case. Each completion takes approximately 10-15 minutes.
Who should use this Ambulatory Surgery Pre-Operative Checklist?
This checklist is designed for Preop Nurse professionals in the healthcare industry. It can be used for self-assessments, team audits, and regulatory compliance documentation.
Can I download this checklist as a PDF?
Yes, this checklist is available as a free PDF download. You can also use it digitally in the POPProbe mobile app for real-time data capture, photo documentation, and automatic reporting.