Template

Anesthesia and Surgical Care Tracer Tools

by Joven Bilbao, from the Community

30+

This tracer checklist helps hospitals standardize sedation and anesthesia services and align with professional standards and regulations. It covers organization and management, staff competencies, and documentation. Guidance includes pre-sedation risk assessment, preanesthesia and preinduction assessments, anesthesia planning, and continuous monitoring. The tool details patient education, recovery and discharge criteria, and postoperative pain management. Surgical planning and documentation requirements are outlined, along with postsurgical care and plan updates. It also addresses implantable medical devices, including selection, training, adverse event reporting, infection control, device traceability, and recall follow-up.

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Digitize any process, procedure or policy

Eliminate mistakes made by paper-based processes

Create and share professional reports instantly

Confirm accountability and compliance with a digital log

About author

Community

This community page makes available free workplace checklists and templates created by other users within the SafetyCulture community. SafetyCulture has re-published this content and where possible, has credited the original author. SafetyCulture has not verified the accuracy, reliability or suitability of any community content. You agree that your use of any of this content is in accordance with SafetyCulture’s Terms and Conditions.

Template
CMS Requirements for Anesthesia Services
This resource summarizes CMS Conditions of Participation for Anesthesia Services and how hospitals can remain compliant. It explains organization and staffing requirements, including who may administer anesthesia and CRNA supervision rules, outlines pre-anesthesia evaluation, intraoperative record, and postanesthesia evaluation standards, and emphasizes rescue capacity, safety practices, and integration with QAPI. Use it to align policies, documentation, and training with recognized standards of anesthesia care.
by Chad Niemeyer, from the Community
Downloads: 10+
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Template
Anesthesia Infection Prevention Assessment Checklist
This anesthesia infection prevention assessment checklist helps hospitals and surgical centers audit compliance with infection prevention and control standards. It covers policies and procedures, hand hygiene and glove use, personal protective equipment, clean and dirty environment setup, workflow practices, injection and medication safety, intravenous therapy, neuraxial procedure precautions, respiratory care equipment, disinfection of anesthesia equipment and rooms, and exposure management. Use it to standardize practice, reduce infection risks, and support staff training and quality improvement.
by Sadia Akram, from the Community
Downloads: 0
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Template
JHH OR and Procedure Tracer
This document outlines comprehensive guidelines for surgical and procedural documentation in healthcare settings. It covers essential requirements for patient safety and medical record keeping, including pre-operative documentation, H&P updates, informed consent procedures, anesthesia protocols, and post-operative documentation standards. The guidelines detail specific timeframes for documentation completion, safety protocols such as site marking and time-out procedures, medication handling requirements, and post-anesthesia evaluation criteria. It also includes requirements for immediate and detailed post-operative notes, discharge documentation, and equipment handling procedures. These standards ensure compliance with healthcare regulations while maintaining patient safety and proper medical record documentation.
by Aileen Almario, from the Community
Downloads: 60+
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Template
JHH Adult Inpatient Tracer Tool
This JHH Adult Inpatient Tracer Tool supports hospital teams in auditing end-to-end inpatient care and documentation. Sections cover nursing and provider documentation, pre-op checks, anesthesia consent and assessments, surgical time-outs, post-anesthesia evaluations, H&P requirements and updates, procedural informed consent, immediate and detailed post-op notes, and restraint use with orders, assessments, and education. It also guides nursing plans of care, admission screening, medication reconciliation, critical action value notifications, fall protocols, patient education, pain assessment and management, advance directives, medication ordering and administration safety (including chemotherapy), VAD and central line checklists, infection prevention practices, equipment management, emergency preparedness, patient environment standards, alarm response, and EVC cleaning audits.
by Anne Steele, from the Community
Downloads: 30+
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Anesthesia and Surgical Care Tracer Tools

About author

You might also like

CMS Requirements for Anesthesia Services

Anesthesia Infection Prevention Assessment Checklist

JHH OR and Procedure Tracer

JHH Adult Inpatient Tracer Tool

You might also like

CMS Requirements for Anesthesia Services

Anesthesia Infection Prevention Assessment Checklist

JHH OR and Procedure Tracer

JHH Adult Inpatient Tracer Tool