Pre-Operative Nursing Assessment Checklist
Comprehensive pre-operative nursing assessment ensuring patient readiness for surgery including physical, emotional, and documentation preparation.
- Industry: Healthcare
- Frequency: Before every surgery
- Estimated Time: 20-30 minutes
- Role: Pre-Op Nurse
- Total Items: 48
- Compliance: AORN Guidelines, Joint Commission Universal Protocol, CMS CoP
Patient Identification
Identity verification
- Patient identified using two identifiers?
- Wristband accurate and legible?
- Allergy band applied (if applicable)?
Consent Verification
Surgical consent
- Surgical consent signed and complete?
- Consent matches scheduled procedure?
- Anesthesia consent signed?
Pre-Op Preparation
Patient preparation
- NPO status verified?
- Bowel prep completed (if ordered)?
- Pre-op shower completed?
- Jewelry and valuables removed/secured?
- Dentures/prosthetics noted?
Health Assessment
Physical status
- Vital signs within acceptable limits?
- H&P current (within 30 days)?
- Labs reviewed and acceptable?
- EKG reviewed (if applicable)?
- Imaging available (if needed)?
Medications
Medication review
- Home medications reviewed?
- Medications to hold identified?
- Pre-op medications given per order?
Surgical Site
Site marking
- Surgical site marked by surgeon?
- Patient verified site marking?
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
Related Healthcare Checklists
- Post-Operative PACU Assessment Checklist
- Specimen Labeling Verification Checklist
- Sepsis Screening Protocol Checklist
- Medical Record Audit Checklist
- Clinical Alarm Management Checklist
- Medication Error Prevention Checklist
- Patient Identification Verification Procedure Checklist
- Safe Patient Handling and Mobility Checklist
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Why Use This Pre-Operative Nursing Assessment Checklist?
This pre-operative nursing assessment checklist helps healthcare teams maintain compliance and operational excellence. Designed for pre-op nurse professionals, this checklist covers 48 critical inspection points across 12 sections. Recommended frequency: before every surgery.
Ensures compliance with AORN Guidelines, Joint Commission Universal Protocol, CMS CoP. Regulatory-aligned for audit readiness and inspection documentation.
Frequently Asked Questions
What does the Pre-Operative Nursing Assessment Checklist cover?
This checklist covers 48 inspection items across 12 sections: Patient Identification, Consent Verification, Pre-Op Preparation, Health Assessment, Medications, Surgical Site, 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 before every surgery. Each completion takes approximately 20-30 minutes.
Who should use this Pre-Operative Nursing Assessment Checklist?
This checklist is designed for Pre-Op 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.