Knee Replacement Surgical Checklist Form
Complete this checklist to ensure all pre-surgery requirements for knee replacement are met.
Patient Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Surgery Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Surgical Site
*
Left Knee
Right Knee
Both Knees
Medical Readiness Confirmed (e.g., recent test results, physician clearance)
*
Yes, all required tests and clearances are complete
No, pending items remain
Current Medications and Anticoagulants Reviewed
*
Yes, reviewed and documented
No, review pending
Allergies (including drug, latex, adhesive, or food)
*
Fasting Status Confirmed (as per instructions)
*
Yes, fasting as instructed
No, not fasting
Pre-Operative Instructions Understood and Followed
*
Yes, all instructions understood and followed
No, clarification needed
Transport/Escort Arranged for Hospital Discharge
*
Yes, arrangements confirmed
No, arrangements pending
Submit Checklist
Should be Empty: