Ambulatory Surgical Facility Preoperative Screening and Assessment Checklist

The components of this sample checklist are intended as a cue for ambulatory surgical facilities to confirm that the essential items needed for screening patients preoperatively are included on an existing nursing-based preoperative screening form.

Specific instructions for use are included in the checklist, which may be downloaded for electronic entry or printed for handwritten entry.

Ambulatory Surgical Facility Preoperative Screening and Assessment Checklist

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