Operating Room Protocol Form
Complete this form to review and coordinate the operating room protocol before a procedure.
Procedure Date and Time
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Patient Initials or Case Number (no sensitive data)
*
Type of Procedure
*
Please Select
General Surgery
Orthopedic
Cardiac
Neurosurgery
ENT
Other
Lead Surgeon Name
*
Anesthesia Provider Name
*
Nursing Team Lead Name
*
Pre-Procedure Checklist Completed?
*
Yes
No
In Progress
Equipment and Supplies Checked?
*
All Ready
Pending
Issues Noted
Infection Control Measures Confirmed?
*
Yes
No
Pending
Additional Notes or Concerns
Submit Review
Should be Empty: