Surgical Safety Checklist Audit Log
Use this form to record and review completion of a surgical safety checklist audit for a procedure or operating room case.
Audit Details
Audit Date
*
-
Month
-
Day
Year
Date
Audit Time
*
Hour Minutes
AM
PM
AM/PM Option
Facility / Hospital Name
*
Department / Unit
*
Please Select
Surgery
Anesthesiology
Nursing
Perioperative Services
Orthopedics
General Surgery
Obstetrics
Other
Operating Room / Procedure Area
*
Procedure Name / Type
*
Checklist Review
Checklist stage audited
*
Sign in
Time out
Sign out
Full checklist
Checklist items reviewed
*
Rows
Verified
Not verified
Not observed
Patient identity confirmed
1
2
3
Procedure and site confirmed
4
5
6
Consent verified
7
8
9
Allergies reviewed
10
11
12
Required equipment available
13
14
15
Antibiotic prophylaxis confirmed
16
17
18
Surgical count completed
19
20
21
Specimen labeling verified
22
23
24
Compliance status
*
Compliant
Partially compliant
Non-compliant
Not observed
Audit Findings and Follow-Up
Audit findings or observations
*
Corrective actions required
Priority of follow-up
*
Low
Medium
High
Urgent
Other
Follow-up or recheck date
-
Month
-
Day
Year
Date
Additional comments or recommendations
Submit Audit Log
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