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Time Out Audit
Time Out Audit
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Created by Qualaris Staff
Critical Access Hospital
Operating Room
Table of Contents
Audit Form
Audit Form
Time Out Audit
Required
Observed Date
Time Out Initiated by:
Surgeon
RN
Time Out Audit Checklist
Mark all as...
Patient ID
Yes
No
ID Band/Name/DOB
Yes
No
Surgical Consent within 30 days
Yes
No
Anesthesia Consent
Yes
No
N/A
Allergies Documented
Yes
No
Pre Antibiotics
Yes
No
N/A
H&P within 7 days
Yes
No
Fire Risk
Yes
No
N/A
Entire Team Participates in Time Out
Yes
No
Correct Patient, Procedure, Site
Yes
No
Consent Verified and Signed
Yes
No
Site Marked and visible by all
Yes
No
N/A
Correct Equipment/Xrays/Implants Available
Yes
No
N/A
Prep Dry
Yes
No
N/A
