7/27/2019 Attachment for Time Out and Site Marking (Opd)

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Attachment No. 1

Non-Operative SettingSite Verification/Marking and Time Out

Affix Label Here (If Available)

Name:

DOB: ..

ID Number:

Patient LabelPatient LabelDepartment where procedure is being performed:

Dental Department Dermatology Department

Emergency Department In-patient

ENT Department Surgical Clinic Endoscopy Unit

Name of Procedure:

..

Complete the following if marking of procedure site is applicable: (check all that apply) Patient/ family participated in marking

Consistent with Consent

Patient refuses site marking because: ...

* Marking is on marking form attached to chart Yes No

Others (specify):

Site marked by:

Time Out Before Procedure Begins:Complete this part just before starting the procedure and involvethe entire/procedural team using active communication.

Verify the following (as applicable): Correct patient using two patient identifiers Consent available Agreement on Procedure Correct patient position Verification of Site and Side Availability of correct equipments/special equipment(s)

Time Out Participants:

(check all that apply) Physician Anesthetist Nurse Technician Others(specify)

Form Completed by :

.(Signature, Name and Stamp if applicable)

Date: Time:

7/27/2019 Attachment for Time Out and Site Marking (Opd)

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Use the diagram below for marking the correct surgical site in the following situations:1. If the patient refuses to be marked.2. If the surgical site involves genitalia or other site with a left /right distinction that cannot be

marked.

Signature of Patient /Family Member Verifying Site (as applicable)

Site marked on this form by:

(Signature, Name and Stamp of physician)

Date: Time:

Please place this form on top of the chart for reference during the surgicalprocedure

Disclaimer: Site marking on this form has been done as an alternative tool and the marking is confirmedby the patient/next of kin

Front

RightSideLeft Side on Both

Right Side

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