Anesthesia Procedure Checklist
Complete this checklist to ensure all safety and procedural steps are followed for anesthesia administration.
Patient Full Name
*
First Name
Last Name
Date of Procedure
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Type of Procedure
*
Type of Anesthesia
*
General Anesthesia
Regional Anesthesia
Local Anesthesia
Sedation
Other
Anesthesia Provider Name
*
First Name
Last Name
Pre-Anesthesia Assessment Completed?
*
Yes
No
Airway Assessment Completed?
*
Yes
No
Equipment and Medication Check (tick all completed)
*
Oxygen supply checked
Suction equipment ready
Airway equipment prepared
IV access established
Monitors attached
Emergency drugs available
Other
Patient Identity and Procedure Confirmed?
*
Yes
No
Consent for Anesthesia Confirmed?
*
Yes
No
Additional Comments or Observations
By signing below, I confirm that all items on the anesthesia checklist have been reviewed and completed to the best of my knowledge.
*
Submit Checklist
Submit Checklist
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