Pre Operative Note
The short checklist written the night before, so nothing stops the case in the morning.
Pre-op diagnosis
The diagnosis the patient is going to the operating room for.
Procedure
The planned surgery.
Labs
CBC, chemistries, PT/PTT, urinalysis.
Chest x-ray
Note the findings.
EKG
Note the findings.
Blood
Not needed, type and screen, or type and cross 2 units of packed red cells.
Orders
NPO, pre-operative antibiotics, skin or bowel preparation.
Consent
Signed and on the chart, if so.
The two things that cancel cases
A missing consent and a missing type and screen. Check both yourself the night before rather than assuming somebody else did.