Preoperative Nursing Checklist Form
Use this form to review preoperative readiness, document key nursing checks, and record any notes before surgery begins.
Patient and Procedure Details
Patient Name
*
First Name
Middle Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Scheduled Procedure Name
*
Procedure Date and Time
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Operating Area / Department
*
Preoperative Nursing Checklist
NPO status verified
*
Yes
No
Not applicable
Allergies reviewed
*
Yes
No
Not applicable
Vital signs recorded
*
Yes
No
Not applicable
Pre-op medication given
Yes
No
Not ordered
IV access confirmed
*
Yes
No
Not applicable
Surgical site marked
Yes
No
Not applicable
Consent present in chart
*
Yes
No
Not applicable
Patient belongings secured
Yes
No
Not applicable
Nursing Notes and Handover
Notes / Remarks
Nurse Name
*
First Name
Last Name
Nursing Sign-off
*
Submit
Submit
Should be Empty: