Standards › Standard 6 › Forms
Form · DAY-FRM-004 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 6.5
Purpose
Records the pre-procedure checks for each day-surgery patient.
How to complete
- Complete before the patient goes to theatre.
- Record any check not done and the action.
- Sign by the nurse and the surgeon.
Checks
| Check | Entry |
|---|---|
| Identity checked against the list | Yes |
| Consent signed and in the notes | Yes |
| Fasting confirmed | Yes |
| Allergies recorded | Yes |
| Medicines reconciled | Yes |
| Imaging and results available | Yes or N/A |
| Signed by nurse and surgeon | Yes |
Evidence
| Reference | Note |
|---|---|
| E-009 | Based on the WHO Surgical Safety Checklist (2009). |
| E-006 | ASF Policy Framework v1.2. Adapted. |
| E-009 | ASF Expert Committee consensus. |
Change history
| Version | Date | What changed | Approval |
|---|---|---|---|
| 1.0 | the date of approval | First version | set Expert Committee approval |
E-learning for this document
- Ophthalmology & Day Surgery Safety (AMB-15)
- Patient Identification, Informed Consent and Patient Rights (T-07)
References
- Accréditation Sans Frontières (2026). ASF Policy Framework v1.2. (E-006)
- Accréditation Sans Frontières (2026). ASF Expert Committee consensus on Standard 1. (E-009)