The significance of having the preoperative checklist is that the careful preparation of

individuals undergoing surgery during the preoperative period decreases operative risk and
promotes postoperative recovery. Essential preparation must be thorough. Each client responds
differently to surgery and there are many variables that influence a persons response to surgery
and these variables reveal the degree of risk for a client undergoing surgery. So in the
preoperative checklist, the patient is prepared for surgery and also the nurse is gathering baseline
information in order to plan the care of the patient so that when the time comes for the patient to
undergo the surgery, it will be with the necessary precautions already and the Operating team can
anticipate what the patient might manifest inside the OR because the patient has been assessed
accuratel.

Classification of incisions :
The incisions used for exploring the abdominal cavity can be classified as :
(A) Vertical incision :
(i) Midline incision
(ii) Paramedian incisions
(B) Transverse and oblique incisions :
(i) Kocher's subcostal Incision
(a) Chevron (Roof top Modification)
(b) Mercedes Benz Modification
(ii) Transverse Muscle dividing incision
(iii) Mc Burneys Grid iron or muscle spliting incision
(iv) Oblique Muscle cutting incision
(v) Pfannenstiel incision
(vi) Maylard Transverse Muscle cutting Incision
(C) Abdominothoracic incisions

75-041 (12/06)

NURSING PREOPERATIVE
CHECKLIST
OP0070

To be completed 24 hours prior to surgery

INSTRUCTIONS: Indicate that the task has been completed or the proper form is on the chart by
initializing the item.
Place NA in the column if item does not apply. Sign full name and title at bottom of page. Complete new
form for each surgery procedure date.
REVIEW MEDICAL RECORD AND PHYSICIANS ORDER: INITIALS
1. History and Physical completed and in chart ..........................................................................
1. ____
2. Laboratory studies/Reports in chart .............................................................................................. 2. ____
3. EKG report in chart .................................................................................................................. 3. ____
4. Chest X-ray report in chart ........................................................................................................ 4. ____
5. Operative Permit completed, signed, & witnessed in chart .......................................................... 5. ____
_ Patient Affirmation _ Witness Affirmation _ Physician Attestation
6. Anesthesia Permit completed, signed, & witnessed in chart ..................................................
6. ____
_ Patient Affirmation _ Witness Affirmation _ Physician Attestation
7. Consent for blood transfusion completed, signed, & witnessed in chart .................................... 7. ____
_ Patient Affirmation _ Witness Affirmation _ Physician Attestation
8. Medication Reconciliation Form Completed & Signed..................................................................8. ____
9. 4 pages of labels ............................................................................................................................9. ____
PREOPERATIVE PREPARATION: INITIALS
1. Identification bracelet accurate and affixed to wrist or ankle prior to transport ...................... 1. ____
2. Allergies checked, allergies bracelet on and allergy sticker on chart ........................................ 2. ____
3. Isolation label on chart .................................................................................................................. 3. ____
4. Jewelry, hairpieces, hairpins, contact lenses, glasses, prosthesis, underwear, money removed .. 4. ____
5. Vital signs taken and recorded ................................................................................................ 5. ____
Time taken_________ BP_________ Temp_______ HR_______ Resp_______ FS_______
6. ____
6. Dentures: _ Full: _ Upper _ Lower _ Partial: _ Upper _ Lower
_ Other:_____________________________________________
_ Removed: _ Sent Home _ Left at bedside
_ Left in place as requested by: _ Anesthesiologist _ Patient
7. Patient NPO _ yes since ________ _ no ............................................................................
7. ____
If no: O.R. notified (Time) _______ (Whom)..............................................................................
8. Medication sheets on chart......................................................................................................... 8. ____
9. Most recent nursing assessment attached.................................................................................... 9. ____
10. Report called to ____________________________________ at_____________(time) ........ 10. ____
INITIALS

SIGNATURE and TITLE

INITIALS

THE GEORGE WASHINGTON UNIVERSITY HOSPITAL. OP0070

SIGNATURE and TITLE

Preoperative checklist
and
surgical incision sites

Submitted to:
Asst. Prof. Kathleah S. Caluscusan

Submitted by:
Lea Luz Marie D. Tan pastor