Nasogastric Tube Placement Verification Checklist Form
Use this form to document nasogastric tube placement verification before the tube is used. Keep the form title exactly as written.
Verification Details
Patient or Record Identifier
*
Date and Time of Verification
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Tube Insertion or Placement Reference
Verification Purpose / Status
Please Select
Initial placement check
Routine reassessment
Post-adjustment verification
Prior to feeding/medication
Completed
Other
Placement Confirmation Checks
Methods Used to Verify Placement
*
Aspiration
pH Check
Imaging Review
External Length/Marking Check
Clinical Observation
Other
Aspirate Appearance
Please Select
Clear
Cloudy
Milky
Green/Yellow
Brown
Blood-Tinged
No Aspirate Obtained
Other
pH Result
External Tube Marking / Length at Nares or Reference Point
Final Verification Outcome
*
Confirmed
Not Confirmed
Pending Review
Actions and Completion
Immediate action taken
*
Restrictions before use
Staff name / role or department
*
Submit
Should be Empty: