Radiofrequency Ablation Procedure Checklist Form
Complete this checklist to ensure all critical steps are followed for a safe and effective radiofrequency ablation procedure.
Patient Initials
*
Date of Procedure
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Indication for Procedure
*
Please Select
Chronic pain management
Arrhythmia treatment
Tumor ablation
Other
Procedure Site Confirmed
*
Yes
No
Allergies Reviewed
*
Yes
No
Anticoagulation Status Checked
*
Yes
Not applicable
Equipment Functionality Verified
*
Generator tested
Electrodes/catheters checked
Imaging equipment ready
Intra-procedure Monitoring Initiated
*
Yes
No
Immediate Post-procedure Instructions Provided
*
Yes
No
Submit Checklist
Should be Empty: