PRINCIPLES-BASED CHECKLIST TO USE WITH ALL PROCEDURES
Procedure # Procedure Title
Check (✓) S (Satisfactory) or NI (Needs Improvement)
PROCEDURE STEPS S NI COMMENTS
Before Approaching Patient:
• Checks records (e.g., medication record) or obtains a
prescription, if necessary.
• Refers to agency protocols, if not familiar with them.
• Obtains signed informed consent, if needed.
• Performs hand hygiene; dons procedure gloves, if needed.
• Gathers supplies and equipment before approaching
patient.
• Obtains assistance, if needed (e.g., to move a patient).
Preparing Patient:
• Introduces self and instructor to patient.
• Identifies patient: reads wrist band, and asks patient to
state his name. Follows agency protocol.
• Makes relevant assessments (e.g., takes vital signs) to
ensure that patient still requires the procedure, is able to
tolerate it, and that there are no contraindications.
• Explains the procedure to patient, including what he will
feel and need to do (e.g., “You will need to lie very still”).
• Provides privacy (e.g., asks visitors to step out, drapes
patient). Uses good body mechanics: positions bed or
treatment table to a working level; lowers the near
siderail.
• Uses good body mechanics: positions bed or treatment
table to a working level; lowers the near siderail.
During the Procedure:
• Performs hand hygiene before touching patient, before
gloving, after removing gloves, and again before leaving
the room.
• Observes universal precautions (e.g., dons and changes
procedure gloves when needed).
• Maintains sterility when needed.
• Maintains correct body mechanics.
• Provides patient safety (e.g., keeps siderail up on far side
of the bed).
• Continues to observe patient while performing the
procedure steps and pauses or stops the procedure if
patient is not tolerating it.
• Performs the procedure within an acceptable time period.