Presurgical Checklists Promote Good Documentation Practices

By Dean C. Brick, MD

[Digest, Fall, 1991]

A presurgical checklist helps ensure that all aspects of surgery, including informed consent, patient compliance and postoperative complications, are discussed with the patient. This cataract surgery checklist was developed by Byron H. Demorest, MD, and Richard A. Deutsche, MD, of the OMIC Risk Management Committee.

Prior to scheduling surgery

• Alternative therapies have been explained.
• No surgery
• Surgery

• Procedure electives have been discussed.
• Spectacles
• Contact lenses
• IOL

• Postoperative complications have been discussed with patient and, if appropriate, with patient's family.



• Patient has been told that results are not guaranteed and surgery could result in:
• No improvement in vision
• Worse vision (even total blindness)
• Improvement in vision

• Patient has been told that the implant might have to be removed, replaced, or become dislocated and have to be repositioned.



• Patient has been told about other possible complications of surgery including:
  • Astigmatism
  • Image size difference
  • Need for prolonged medication
  • Infection
  • Retinal detachment
  • Corneal damage
  • Double vision
  • Hemorrhage
  • Lid droop
  • Pupil distortion
  • Pain
  • Glaucoma
  • Uveitis
  • Capsule clouding requiring laser treatment

• Anesthesia options have been reviewed (general or local) and patient has been told about possible complications of anesthesia including:
• Drug reactions
• Brain damage
• Death

At appointment preceding surgery

• Informed consent form has been reviewed and signed.*



• Medical evaluation has been performed.



• Preoperative eye exam has been performed.


• Visual acuity
• Description of cataract
• IOP
• Macular function
• Appearance of the optic nerve

• Lab tests have been performed, if indicated, and reviewed.
• CBC
• Urinalysis
• Chempanel
• EKG
• Chest x-ray

• Patient's medication and medical history have been reviewed.
• Is patient currently taking any medications?
• Is patient allergic to any medications?

• IOL calculations reviewed.
• Determine proper IOL power

• IOL has been ordered.
• Posterior chamber lens
• Anterior chamber lens
• No implant

• Patient has been instructed on preoperative facial care.


• Facial cleansing prior to surgery


• No cosmetics on day of surgery

• Patient has been instructed on any preoperative drops.



• Patient has been instructed on diet on day of surgery.



• Patient has been told what time to arrive for surgery and what time to expect to be able to go home.



• Patient has arranged an escorted ride to and from surgery.



• Postoperative follow-up appointment has been scheduled.



• Eye has been examined for infection of globe and lids.

On the day of surgery

• Confirm patient's name.



• Confirm which eye for surgery.



• Prior to mydriatic drop, look for signs of discharge or infection of globe or lids.



• Confirm that you have the correct IOL for that patient when you are in the operating room.

* Note in patient record that alternative therapies, risks and complications have been reviewed and signed by the patient and witness.