Published 21 Dec 2022
What is a Medical Checklist?
A medical checklist is an itemized document used for various procedures and protocols in healthcare settings. It functions as a guide for carrying out medical procedures safely and correctly, whether a physical examination or a surgical operation. Using this checklist, healthcare professionals can provide the best possible care for their patients.
Medical Checklist for Surgical Safety (WHO)
Based on the World Health Organization (WHO)’s framework, this medical checklist provides a step-by-step guide to performing surgeries safely. Surgical teams can utilize this checklist to:
- Describe the surgery type, date, time, location, and people involved in the operation
- Run through the necessary steps prior to the induction of anesthesia
- Verify essential matters and determine any foreseeable critical events with the surgeon and anesthetist before beginning the procedure
- Confirm the completion of the surgical procedure with the nurse, surgeon, and anesthetist
- Document any health concerns or issues that arose during the operation
The checklist can easily be modified and tailored in SafetyCulture (formerly iAuditor) according to the needs and practices of the institution. Once the procedure is complete, surgical providers can automatically generate surgical reports in PDF, Word, Excel, and other formats.
In this article
- What to Include in a Medical Checklist
- FAQs about Medical Checklists
- Enhance Patient Safety with a Digital Checklist
- Featured Medical Checklists
Medical checklists are a vital part of any medical practice. For instance, they outline the steps in carrying out medical processes in a clear and concise manner that healthcare staff can easily follow. With the help of this tool, medical professionals can perform all crucial steps accurately and account for all necessary items in a procedure without missing anything. This way, they can minimize deadly errors and maximize patient safety.
A medical checklist also helps improve communication and coordination between providers and patients. It ensures that all healthcare team members are aware of the patient’s condition and treatment plan and can help to prevent or catch errors, especially for high-risk operations. In fact, various studies suggest the effectiveness of using checklists in medical environments, as it has enabled providers to deliver quality patient care and improve outcomes in various settings, such as the operating room and the intensive care unit (ICU).
Medical checklists come in different kinds depending on the situation and intended purpose. Some of its most common types and uses include:
- General medical checklist – used to improve the safety of standard medical procedures such as surgical operations from the pre-operative to the post-operative phases.
- Medical history checklist – used to collect all relevant patient information during the history-taking process; a great tool for tracking patient progress and proactively spotting health problems.
- Medical audit checklist – used to verify if specific areas and procedures (e.g., clinical services, nursing care, and medication) are carried out accurately and in accordance with the set guidelines and protocols
- Administrative form – used to check if patient transfers, discharges, laboratory testing, and other procedures are carried out as intended.
- Compliance checklist – used to confirm if healthcare providers follow regulations and standards for patient care, data privacy, and medical records from agencies such as the Occupational Safety and Health Administration (OSHA), Health Insurance Portability and Accountability Act (HIPAA), and the Care Quality Commission (CQC).
- Hospital safety inspection checklist – used to promote safety in the medical premises, including proper housekeeping and cleaning procedures.
- Clinical audit checklist – used to review clinical outcomes and patient care against industry standards and established benchmarks.
What to Include in a Medical Checklist
A medical checklist is a great way to organize and keep track of procedural instructions and vital patient information. Each checklist will contain different information based on its function and setting, but in general, it’s essential to include the following information when creating one:
- Title Page – This section specifies the date, time, and the people or team involved in the procedure or check-up. It can also include the patient’s name, contact information, medical history, current conditions, and treatments, as well as any allergies.
- Pre-operative Check – This section lists essential tasks before starting a consultation, procedure, or laboratory test. For example, if it’s for a surgical operation, the checklist must indicate things to do before inducting anesthesia and creating a skin incision.
- Operational Procedure – This section outlines the required steps to be performed and anticipated critical events during a medical procedure or testing. It ensures that the process goes as planned without missing any vital points.
- Post-operative Check – This section runs through a series of tasks to be completed after performing the procedure and before discharging the patient. For example, a medical checklist for surgical operations can verify if the instrument count, specimen labeling, and equipment check are accomplished before the patient leaves the operating room.
- Sign-off – This section gives the physician, nurse, or other healthcare staff in charge a space to note their observations during the medical procedure and affix their signature as proof of completion.
Here is a sample report of a medical checklist for surgical operations, completed using a digital tool:
FAQs about Medical Checklists
In some countries, the use of medical checklists for surgical procedures is mandated by law. For example, all hospitals under the National Health Service (NHS) in the United Kingdom must follow the guidelines set in the WHO Safe Surgery Checklist. But whether required or not, medical checklists are powerful instruments for safely carrying out medical procedures.
Maximize the use of medical checklists using the following tips:
- Tailor the checklist to the specific setting and procedure.
- Structure it in such a way that is easy to use and understand.
- Regularly update the checklist to reflect changes in medical best practices.
- Train staff members on how to use the checklists effectively.
- Integrate medical checklists into a broader safety program for healthcare settings.
Among the common challenges when creating and using paper-based medical checklists are as follows:
- Tailoring checklists according to the ever-changing requirements
- Taking too much time to create and replicate checklists manually
- Feeling the burden of checking off items from the checklist (known as “checklist fatigue”)
- Lacking means to establish accountability in accomplishing these forms
- Having the risk of losing, damaging, or destroying these documents
Enhance Patient Safety with a Digital Checklist
Patient safety is integral to every medical procedure for healthcare providers. A simple but effective way to guarantee this is through the use of a medical checklist. This tool enables medical teams to perform procedures safely and accurately, which leads to improved patient outcomes.
However, paper-based checklists can consume too much time and get lost in the fast-paced nature of most medical settings, rendering them inefficient in the long run. To save time and ensure that every step in procedures is being followed, healthcare providers can digitize their checklists using tools like SafetyCulture.
SafetyCulture, the world’s leading operations platform, is a powerful tool for streamlining and standardizing medical processes across all teams. Available as a web-based software and mobile app, this platform enables healthcare professionals to:
- Create medical checklists by customizing templates from the Public Library, converting their existing paper forms into digital ones, or building their own from scratch.
- Set access controls and permissions for specific people to protect critical patient information and ensure confidentiality at all times.
- Cascade important updates and best practices in using medical checklists via Heads Up.
- Capture issues and nonconformities, take annotated photos, record videos, and note vital observations from a handheld device.
- Keep medical equipment in good condition through regular maintenance checks and automated monitoring systems.
Browse our collection of medical checklists below and see which one best fits your use case.
Featured Medical Checklists
Medical Audit Checklist
Use this digital medical records audit checklist to confirm if current clinical documentation complies with national regulations or industry standards. Review existing patient records and medical documents from your handheld device, provide additional recommendations for current documentation practices, and sign off the form as proof of completion.
Nursing Report Sheet
Nursing staff can use this nurse report sheet during ward or room visits. Start with the patient’s general information, diagnosis, and medical history. Then, record vital signs such as heart rate, blood pressure, temperature, and blood sugar. Make sure to document the medicines dispensed and the patient’s food intake. Lastly, note any future procedures for the succeeding nurses. Use SafetyCulture to run digital patient checks and customize this template based on your needs.
Nursing Audit Checklist
Use this nursing audit checklist to verify compliance with proper nursing documentation and assess nursing care provided to admitted or discharged patients. Review clinical records, note areas for improvement, and ensure consistent quality patient care with this checklist.
Hospital Safety Inspection Checklist
This hospital safety inspection checklist can assist inspectors in checking the safety of clinical and non-clinical departments in hospitals. It covers general safety measures and specific areas such as hazardous materials, fire prevention, and more.
Infection Control Audit Checklist
This infection control audit checklist can be used to verify if the baseline control measures against medical-related infections are completed. Health and safety officers use this tool to assess the cleanliness of patient rooms, hospital wards, isolation rooms, and other facilities. This checklist can also be used to evaluate the hospital staff’s competence in following and implementing infection control measures.
COVID-19: Screening Checklist for Visitors and Employees
This COVID-19 screening checklist can be used by healthcare and assisted living providers to help ensure the safety of their institutions and prevent the spread of the COVID-19 virus. Please remember that this screening checklist provides basic information only. It is not intended to take the place of medical advice, diagnosis, or treatment.
COVID-19 Cleaning and Personal Hygiene Inspection Checklist
Use this inspection checklist to ensure that the CDC guidelines for cleaning and personal hygiene are being observed on the hospital premises. Check if staff members follow the steps for cleaning and disinfecting surfaces and are wearing appropriate Personal Protective Equipment at all times to control the spread of COVID-19 with this form.
Hospital Housekeeping Checklist
Use this checklist to standardize housekeeping practices in healthcare facilities. Start by specifying the unit and room to be cleaned, then check on its isolation status. Ensure proper hand hygiene and PPE while performing housekeeping tasks. Take photos of cleaned patient rooms and add annotations for high-touch surfaces. Lastly, complete the form with a digital signature and instantly generate a hospital housekeeping report before leaving the room.
Medical Waste Monitoring Checklist
This waste monitoring checklist is used to confirm compliance with medical waste management standards. Using this checklist, ensure that medical waste is being properly managed by your personnel and note any recommendations for infection prevention and waste disposal from medical waste products.
Patient Satisfaction Survey
Use this patient satisfaction questionnaire to quickly determine the level of patient satisfaction with the medical care provided and gain insights to improve existing services. Conduct this survey via kiosks inside the hospital or mobile devices administered by hospital staff.