Standard Operating Procedures: Surgical/Medical Camps
Indian Medical Association
Prof. (Dr.) Rajeev Sood
Dr. Raman Tanwar
2014
Table of Contents
Roles and responsibilities of programme managers and service providers........ ..........5
Processing of Equipment, Instruments and other Reusable Items............................. 8
Why is there a need for SOPs for surgical/medical camps in India? Inadequate institution based services are unable to meet the present need of Indian population because of a large patient load spread across a wide area. A camp based approach has the advantage and flexibility of delivering healthcare to the patients at their doorsteps, but quality of care often becomes an area of concern. Guidelines and operation protocols can help to minimize complications which are the prime concern in this model of health service delivery. Guidelines can provide direction to the health care provider in ensuring completeness and standardization of care. Adherence to standard operating procedures ensures that all components of health care are delivered in the correct order from counseling to follow up and audit. In the light of concerns about poor outcomes of procedures performed in the camps there is a need to direct providers to a systematic and universal approach in dealing with health care consumers.
Standardization and quality assurance guidelines regarding sterilization camps have been formulated by the government of India in conjunction with an expert committee (2006). The present document is an extension to the existing document and provides directives to all type of personnel involved in conducting any medical/surgical camp with regard to the above mentioned issues from planning and executing to monitoring surgical services. As is true for faithful reproduction and uniform delivery of health services, guidelines must be available and timely revised, they should be accessible and health providers must be aware of these guidelines and they should be implemented at every possible step. If possible feedback regarding problems in practical application of these guidelines must be sought and a working committee should find solutions to the problems in conjunction with local health providers and update the guidelines on a regular basis so that they reflect world standard healthcare. Quality assurance should thus be the prime concern for evolution and better health care delivery by the camps.
The goals provided by the government to provide healthcare services in a given area should be realistic and not over enthusiastic. The government must ensure that the workload assigned is possible in the given settings without violating the guidelines. It is possible that the in-service doctors feel pressurized to fulfil unrealistic targets placed by the government.
This document expands the existence, awareness and implementation aspect of guidelines to ABCDEFs of camp based health care delivery. These ABCs include:
- A: Awareness and Availability of 6S (Survey, Space, Sanitation, Services, Sterility, Staff)
- B: Basic Training – All staff must be trained and sensitized to deliver services in an effective way
- C: Checklist- A checklist of each station must be available and completely filled and implemented before the necessary action
- D: Delivery – Delivery of health care services must be done in a standardized fashion to bring uniformity in approach
- E: Emergency & Exit services – Emergency services must be readily available in case of referral. Counseling regarding dos and don’ts apart from danger signs must be done at exit.
- F: Feedback, Follow up and Future strategy- Exit client interview must be done for feedback and clients must be followed up on a regular basis by means of follow up clinics
A surgical/medical camp is a temporary establishment that provides surgical facilities by a group of medical experts headed by a medical officer, which are routinely not available in that region or center. The camp should not result in duplication of health services and only when there is a strong need should a camp be organized.
The camp must have the provision and manpower to provide counseling, surgical procedures that have been declared, post-operative care, follow up facilities and perform an audit with regards to the services provided. The services that are needed to provide integrated healthcare including facility for referral to a connected higher center in event of any inadvertent complication must be available. Camp must also function as a center for data collection regulated by the appointed nodal officer. IMA through its nodal officer should keep a check on the pressures under which the team executing the camp has to perform.
The NGO's and Individuals should also not be overenthusiastic to the extent of disregarding the laid protocols. The effort made should be towards a mission rather than being a means of propaganda and personal publicity.
The camp should have experience counselors who are engaged in the field of health care and are qualified to address all important issues with regard to counseling. They should be able to guide the patient regarding the need, alternatives and complications associated with the procedure in the language that the patient understands. Surgical procedures should be portrayed as irreversible and each step should be carefully explained to the client. A written informed consent preferably in two languages should then be taken in front of a witness.
The list of services that are within the scope of the camp should be clearly enlisted and presented. The number of procedures that can be offered should be announced at the beginning of the camp. Any additional services should be offered only if adequate manpower is available for the same.
Basic investigations that are necessary before performing the procedure should be available at the camp. These include hemoglobin, bleeding and clotting time, urine sugar and albumin as a minimum.
Pre-requisites for sterilization camps
Only established health care centers should be designated as centers for health camps. The centers should be sterilized before surgical procedures are initiated. There should be a designated theatre, pre-operative area, post-operative area and outpatient and counseling areas in each camp apart from an area to dispense drugs. Counseling area may be used for dispensing the drugs.
The number of operating teams should be the prime determinant of the number of cases that can be operated in one camp. With an estimated number of working hours in one camp being 8 hours for one operating team up to 30 small day care procedures should be permitted. The number of teams required based on expected number of clients must be predefined.
The timings of the camp should preferably be from 8 AM to 4 PM. The initial hour may be utilized in setting up the center and theatre, counseling, investigation and preparing lists. Surgeries may be initiated as soon as the checklist has been verified.
The recommended staff varies based on the surgical procedure planned during the camp. All activities of the camp are supervised by a nodal camp officer who may perform additional roles within the camp and a representative nodal officer form the local body (IMA) who shall assist the government appointed nodal officer at various stations. The minimal staffing required has been summarized as under:
- Registration (1 Staff/Male worker)
- History & Clinical Assessment (One Medical officer along with Staff Nurse)
- Counselor (One Health supervisor or ANM)
- Laboratory Examination( 2 laboratory technicians)
- leaner (one cleaner)
- Pre-operative preparation/Premedication preparation room (one health worker)
- Instrument & reusable items processing/sterilization area ( two OT attendants and one Ward Boy/Aya)
- Operation theatre Personnel ( one Surgeon and one anesthesiologist along with one taff Nurse/ANM , one OT Attendant and one Cleaner)
- Post-operative room (one medical officer along with one staff Nurse)
- Office and store (One Accountant and a pharmacist)
Equipment/Instruments and Supplies
Since the need of instruments varies based on procedure being done exhaustive list of instruments that should be available is out of scope of discussion, however a checklist of instruments used in sterilization camps has been included as an annexure. The number of Instrument sets must be three times the number of operating tables and sterility must be strictly maintained. The number of beds in the post-operative area must correspond to the number of surgeries performed in the camp. Sharing of beds must be avoided.
Roles and responsibilities of programme managers and service providers
Service providers must be self-aware of the individual duties and responsibilities. Every individual should keep a check on personal actions and that of the immediate subordinate. The planning for camp related activity should begin well in advance and the chief medical officer is often the main person responsible for planning and execution. All camps must be organized after due permission by the government. The Government should give permission for the camp after checking the credentials and reinforcing these guidelines. Government authorities should also ascertain through the designated representatives that the camp is conducted as per the said guidelines such if any mishap occurs then the government shall be held responsible for the same. Along with the government the organization responsible for any mishaps during the camp shall be the one that has ordered the camp.
Pre camp activities should be directed at:
- Information to and permission from a nodal officer who is in-charge of all camp related activities in the district
- Designate camp managers both locally and at the district level
- Establishing coalition with the operating team well in advance with the camp managers
- Allocation and Mobilization of the funds
- Assimilation of resources in terms of medical equipment and non-medical equipment including consumables and other staff
- Ensuring IEC in the target area and nearby areas
- Counseling of all members who are part of the camp regarding their definite role and expectations from them
- After camp activities that are required to minimize complications must be clearly defined in the plan submitted to the nodal officer.
During the camp the camp manager/ nodal officer has to coordinate the activities during the camp including availability of equipment medicines and required personnel. Each member of the team should have clear understanding of what is expected from them.
Maintenance of sterility and cleanliness should be the prime concern for the camp manager. Following precautions must be taken for maintaining asepsis:
- OT complex microbial study count must be within permissible limits
- Proper fumigation record of the OT must be maintained
- Fumigation should be done twice for two consecutive days before beginning the camp
- Theatre must be closed for at least 12 hours before the procedures are initiated
- The operating surgeon must be instructed to ensure that the microbe and swab report of the operating room is sterile before any surgical procedures are conducted.
- Cleaning and draping should be given adequate time.
- Hair can be clipped but not shaved.
- Apply detergent based antiseptic solution to remove particulate matter.
- Use iodophors or chlorhexidine at least two times over the operative site in a circular motion from center to periphery and allow 1-2 minutes for iodophors to act.
- Excess antiseptic should not be allowed to pool beneath the patient.
- Apply a sterile drape.
- This process takes about 5 minutes and the procedure should be started only when adequate time has been given to cleaning and draping.
Apart from performing the surgical procedure the duties of the operating surgeon include:
- The operating surgeon should also be in charge of counseling and patient selection and must ensure that the surgery is indicated and the patient is prepared for possible complications.
- The operating surgeon before beginning the procedure must follow the checklist and establish preparedness for any emergency procedures if needed before referral.
- He must also ensure that the patient understands the course after surgery and what is expected out of the patient in terms of self-regulated care.
Patient must be discharged after 8-12 hours or as otherwise deems fit based on the procedure after ensuring fitness for the same after a day care procedure. One sample of packet of each drug should be saved for laboratory examination. Drugs of GMP certified companies that have been passed by the DGCI must be used and dispensed. In medical camps and in post-operative advice after surgical camps use of generics should not be encouraged at the cost of quality. Group photo of the patient group should be taken and submitted to the state nodal officer.
Health care delivery must continue after the camp and adequately trained personnel should be appointed to take care of post-operative queries. A Helpline number must be available to direct patient to the appropriate level of healthcare. A follow up visit must be arranged and the date must be clearly mentioned in the discharge slip.
The conduct of surgical camps requires careful planning as discussed in an earlier section of these guidelines and thorough implementation of every step. These steps have been enumerated in the form of a check list below.
- Sensitization and mobilization of all health care workers concerned to promote information, education and counseling.
- Use of mass media in creating awareness amongst masses including advertisements, hoarding and banners
- Allocation of staff for conduction of the camp and designation of members of the operating team
- Meeting of the staff and operating team regarding division of duties and summarizing the expectations
- Inspection of facility and making arrangements for/ repair of basic amenities for smooth running of the camp including electricity, water supply, sanitation, and allocation of space for waiting, store, counseling and operating rooms.
- Procurements of instruments and sterilization facilities
- Opening of camp facility on time followed by cleaning of the camp
- Division of camp facilities into waiting, registration, counseling, clinical assessment, laboratory, store, office and operating areas
- Division of operating facility into pre-operative area, operating area, post-operative recovery room, sterilization area, scrub area and changing room such that the operating area is in the center/apex of the sterile zone.
- Rechecking or procuring medicines, equipment, sterilized consumables and linen and placing them at the appropriate places
- Rechecking functioning of equipment and managing health care professionals
- Ensuring normal function of the healthcare facility alongside the camp
- Organizing case files and checklists and rechecking all records for completeness
- Organizing follow up activity as per date mentioned on the discharge slip
- Attend to the complication of procedures if any, performed during the camp
- Audit of camp related activities
Prevention of infection: asepsis and antisepsis
Camp based surgical healthcare requires high attention to sterility and antisepsis as it is an important reason why camp based health delivery is considered inferior to fixed facility based delivery. Not only communicable fomite borne infections need to be prevented but serious blood borne infections must also be taken care of. The basic and mandatory steps to prevent infection include:
- Hand washing after every contact in running water with soap or bactericidal solution
- Cleanliness around and within the facility
- Use of gloves and physical barriers and universal precautions
- Adequate sterilization of instruments as advised depending upon the medium of sterilization used in the facility after decontamination
- Cleaning all surfaces that come in contact with the patient with freshly prepared 0.5% chlorine solution (prepared by mixing 15gm of bleaching powder in a liter of water.)
- Entry in the operating premises including recovery should be minimized and only healthy authorized personnel should be allowed to enter.
Processing of Equipment, Instruments and other Reusable Items
- Decontamination must be done before disposal of all consumables and instruments and they must be placed in 0.5% chlorine for at least 10 minutes
- Reusable items must be subsequently cleaned with detergent using a brush and subsequently air dried
Sterilization or High-Level Disinfections (HLD)
- Disinfection can be done using steam, boiling or chemical means depending upon the kind of instrument.
- Instruments must be exposed for at least 20 minutes and all surfaces of the instrument must be exposed to the sterilizing agent.
- Instruments which are not in use should be stored in a dry container
- If preferable steam sterilization should be used and instruments should be wrapped in linen prior to sterilization
- Decontaminated, cleaned, and dried items that are suitable only for chemical sterilization are put in 2% glutaraldehyde solution for at least 8-10 hours after disassembling.
- For use in between cases high level disinfection can be performed by completely immersing the instruments in 2% glutaraldehyde for 20 minutes and rinsing thrice with sterile water.
Disposal of Waste, Needles, and Other Materials
- Waste generated in camps should be managed on the same lines as Biomedical waste for hospitals
Assurance of quality in camp setting
Quality assurance is an important aspect in a camp setting to keep the services at par with fixed facilities. It is a continuous process involving delivery followed by assessment and measurement of improvement.
Like any health system, the camp system of health delivery should seek to make improvements in six areas or dimensions of quality as defined by WHO in 2006, which are named and described below. These dimensions require that health care be:
1. Effective, delivering health care that is adherent to an evidence base and results in improved health outcomes for individuals and communities, based on need.
2. Efficient, delivering health care in a manner which maximizes resource use and avoids waste; the camp based approach is a more efficient form of health delivery
3. Accessible, delivering health care that is timely, geographically reasonable, and provided in a setting where skills and resources are appropriate to medical need; this is one of the prime benefits of health camps
4. Acceptable/patient-centered, delivering health care which takes into account the preferences and aspirations of individual service users and the cultures of their communities; camps reflect this need aptly to the service providers
5. Equitable, delivering health care which does not vary in quality because of personal characteristics such as gender, race, ethnicity, geographical location, or socioeconomic status;
6. Safe, delivering health care which minimizes risks and harm to service users.
- The following need to be monitored for assuring quality care in a camp:
- Facility inputs
- Credibility of the personnel including Physician/Surgeon
- Procedures adopted
- Maintenance of records and registers
- Client care and satisfaction
The District Quality Assurance Committee (DQAC) as well as the Quality Improvement Committee (QIC) along with the nodal officers appointed by IMA and the government must monitor the quality of the camp. The committee should monitor at least 10% of the camps held in the district to ensure quality of care as per the checklists for Client case record, Facility Audit, Observation of Asepsis and surgical procedure, and Client Exit interview laid down in the “Quality Assurance Manual for Sterilization Services“ by Government of India.
Role of Quality Improvement Committee
At each service delivery site sterilization service needs to be monitored and reviewed. This task can be performed by service providers from the facility itself through a process of self-assessment that will identify issues related to quality improvement, help in resolving the identified problems, recommend solutions, and ensure that high-quality services are provided.
The suggested composition of the QIC at District Hospitals/Civil Hospitals/Sub-
divisions/Referral Hospitals is as follows:
- I/C Hospital/Medical Superintendent: Chairperson
- Government Appointed Nodal Official
- IMA appointed Nodal Official
- I/C Operation Theatre/Anesthesia
- I/C Surgeon/Physician
- I/C Nursing
- I/C Ancillary Services (ward boys)
- I/C Transport
- I/C Stores
- I/C Records
At the level of CHC, a smaller committee of 4 to 5 members comprising the Medical Superintendent, I/C Surgeon/Physician, IMA appointed nodal officer, I/C OT, Nursing I/C and other key members of staff should be constituted. The scope of work of this QIC will include all the processes involved in the sterilization services being provided at the camp.
The responsibilities of the QIC will be as follows:
- Identifying critical quality processes in light of the standards for sterilization
- Reviewing the processes with the help of the checklists on client case audit/ facility audit/observation of sepsis and surgical procedure
- Developing a work plan listing activities for improvement and putting this into action
The QIC should meet once a month to review, analyze and recommend solutions to the problems experienced in holding FW Camps and assess the quality of care. This is essential for taking remedial actions for future camps, as camps are to be organized as a regular, fixed day monthly activity at facilities like CHCs and PHCs where regular weekly services are not being provided.
Monitoring of quality of health care being provided in camps should be done at all levels starting from the district level to the national level. Indian medical association should be well knit in this structure at every level. At every level the composition of quality assessment committee must be laid out.
Quality assessment at each level
- At the facility level the in-charge of the camp assisted by the IMA appointed nodal officer should supervise the activities of the camp.
- All case files must be checked and registers must be reviewed for completeness. A client case audit and facility audit must be performed in a prescribed format.
- Procedures must be observed with regards to the surgical technique and asepsis by the visiting team and this team should submit an individual report based on their observation of the procedure, facility and client exit review.
- The nodal officer appointed by the IMA must prepare the camp report and update it on an online register.
- The IMA facility at the district level must be notified about the camp and volunteers should be selected to help in adverse events.
- Any mishap during the camp or related to the camp must be notified to the appointed and the IMA nodal officer for necessary action.
At the state level monitoring on the same lines is to be performed and 10% of the records should be randomly selected for review. Audit must be conducted at the state level as well by the quality improvement committee. Death audit report must be separately prepared and analyzed at all levels.
State QAC should be composed of:
• Secretary, Medical and Health (Chairperson)
• Director, Family Welfare (Convener)
• Director, Medical Education
• One Empanelled Gynaecologist
• One Empanelled Surgeon
• One Empanelled Physician
• One Anaesthetist
• State Nursing Adviser
• Joint Director, (FW)/Deputy Director (FW) or any other as determined by the
• Department of Health and Family Welfare
• One member from an accredited private sector
• One representative from the legal cell
At the central level updating of standardization and quality assurance guidelines must be done by a dedicated committee that conducts timely audits and randomly visits health camps across the country. Such assessments may be performed 1-2 times each month.
- As emphasized earlier the organization ordering the camp along with the government (from where permission to run the camp has been obtained) shall be responsible for the mishap.
- In an event of negligence or mishaps adequate prior investigation must be performed by the investigating officer in association with the medical officer in charge and the nodal IMA officer before any punitive or legal action is taken against the doctor.
- The investigation committee must give a report within a fortnight, well before the charge sheet is filed. Unless proven guilty the offence should be regarded as bailable.
- Any action on the doctor should be taken after a fully vetted and validated process. The issue must be addressed first in a joint committee of the central agency, Medical council of India and the Indian Medical Association before any action is taken.
- Doctor is also a judge who makes fine judgment in regards to a medical condition by implementing his wisdom and experience at every step of the disease management. The medical professional should not be considered a soft target and no shortcuts should be taken in any trial against doctors.
- The investigating officer should obtain independent and competent medical opinion in regards to the facts collected in the investigation and the doctor should in no way be arrested in a routine manner simply because a charge has been levied against the doctor.
- Arrest of the doctor as per the Jacob Mathew case decision by the Supreme Court is warranted only when arrest is necessary to complete necessary investigation, or if the officer feels that the doctor will not be make himself/herself available to face prosecution unless arrested.
Regulation of nodal officers in a state must be performed by a state nominee of the IMA. State nominee must be answerable to the central officer of IMA, in charge of health camps. Under his leadership the guidelines should be updated every 5 years or earlier. The IMA program director may remain at this post for tenure of 5 years.
Annexure 1:
Role of the Nodal officer appointed by the IMA:
IMA has over 1750 branches* across the country and a nodal officer appointed from each branch can play an important role in execution and audit of camp related activities. The role of the IMA nodal officer can be summarized as under:
- Assisting the Nodal Camp officer in various phases of execution of the camp
- Collection of data during the camp and online reporting of the activity
- Performing audit at the level of facility and the district
- Integrating healthcare facility at the higher level in case of referral
- Part of the quality assurance committee
- First referral person along with camp officer in cases of medical mishap/negligence
- Participation in various health programs as a nodal community health representative to generate epidemiological data.
Annexure 2
Emergency Equipment and Supplies:
- Stethoscope
- Blood pressure instrument
- Defibrillator or AED (Automated External Defibrillator)
- Oral airways Guedel sizes 3, 4, 5
- Nasopharyngeal airways, sizes 6, 6.5, 7.0
- Suction machine with tubing and two straps
- Ambu-bag with mask, sizes 3, 4, 5
- Tubing and oxygen nipple
- Oxygen cylinder with reducing valve and flow meter
- Blanket
- Gauze pieces
- Kidney tray
- Torch
- Syringes and needles, including butterfly sets, IV cannula
- IV stand
- Intravenous infusion sets and fluids
- Endotracheal tube, sizes 6, 6.5, 7, 7.5, 8.0
- Laryngeal mask airways, sizes 3, 4, 5
- Combitube
- Cricothyroidectomy set
Emergency Drugs
- Injection Adrenaline
- Injection Atropine
- Injection Diazepam
- Injection Deriphylline
- Injection Xylocard
- Injection Hydrocortisone (Dexamethasone)
- Injection Physostigmine
- Injection Pheniramine Maleate
- Injection Promethazine
- Injection Pentazocine
- Injection Ranitidine
- Injection Metoclopramide
- Injection Calcium Gluconate/Calcium Chloride
- Injection Sodium Bicarbonate (7.5%)
- Injection Dopamine
- Injection Mephenteramine
- Injection Furosemide
- Water-soluble jelly
- Electrode jelly
IV fluids
- Ringer lactate
- 0.9% sodium chloride (normal saline)
- 5% Dextrose
- Glucose 25%
- Hexa starch (HES 6%)
Annexure 3:
List of instruments for performing minilaparotomy:
Sponge-holding forceps 2
Surgical drape (towel with central hole) 1
Syringe, 10 cc 2
Needle, 22-G, 1½" 2
Scalpel 1
Scalpel blade, size 15 2
Allis forceps 2
Medium artery forceps straight 3
Medium artery forceps curved 3
Needle holder 1
Straight scissors 1
Curved scissors 1
Babcock clamp (medium size) 2
Small Langenbeck (right-angle abdominal) 2
Retractor 1
Dissecting forceps, toothed 1
Dissecting forceps, non-toothed 1
Uterine elevator (for interval procedures) 1
Speculum, vaginal, Sim’s medium 2
Small stainless-steel bowl 1
Volsellum 1
Tubal hook, Ramathibodi 1
‘O’ chromic catgut 1
Small round-bodied curved needle 1
Small cutting needle 1
Non-absorbable suture material 1
Dressing material 1
SS kidney tray 1
List of Instruments for performing laparoscopy:
Veress needle (both sizes) 2
Light source for laparoscope with spare bulb 1
Emergency light source 1
Fiber-optic cable 1
Trocar with cannula 2
Operating laparoscope or laparocator 1
Carbon dioxide gas cylinder 2
Pneumoperitoneum insufflation apparatus 1
Fallope-Ring loader 2
Fallope-Ring 2
Dissecting forceps, toothed 1
Scalpel with # 11 blade 1
Sim’s vaginal speculum 1
Uterine sound 1
Uterine elevator 1
Volsellum 1
Straight scissors 1
Needle holder 1
Sponge-holding forceps 2
Catgut suture, 0 or 00 1
Small curved cutting needle 1
Dressing material 1
Iodophor solution 1
Syringe, 10 cc 1
Needle, 22-G, 1½" 1
Gauze 4
Glutaraldehyde container (plastic with cover)1
SS tray (to rinse the laparoscope) 2
SS small bowls 2
SS kidney tray 1
List of Instruments for performing Vasectomy:
Gauze pieces 8
Towel with central hole 1
Mosquito artery forceps, curved 2
Mosquito artery forceps, straight 2
Allis forceps 2
Needle holder 1
Thumb forceps, toothed 1
Metzenbaum scissors 1
Scalpel handle 1
Scalpel blade, size 15 2
Stainless-steel bowl, small 1
Sponge holder 1
Surgical tray with cover 1
Gloves, sizes 6½, 7, and 7½ 2pairs each
Silk suture, 2–0/non-absorbable suture 1
Small round-bodied curved cutting needle 1
Syringe, 5 cc 2
Needle, 22-G, 24-G 1
Suspensory bandage 1
Iodophor solution 1 Q.S.
List of Instruments for performing No Scalpel Vasectomy:
Gauze pieces 6
Towel with central ole 1
Stainless-steel bowl, small 1
Sponge holder 1
Surgical tray with cover (small) 1
Mayo scissors 1
Extra-cutaneous vas fixation ring forceps 1
Vas dissecting forceps 1
Non-absorbable suture (2–0 silk) 1
Gloves, sizes 6½ , 7, and 7½ 2pairs each
Syringe, 5 ml 2
Needle, 22-G, 1.5 inch length, 24-G 2
Iodophor solution Sufficient quantity
Suspensory bandage 1
Dressing material 2
Annexure 4
- Checklist before Surgery:
- Patient Registration Completed
- Indication for surgery checked
- Informed consent taken after counselling
- Known allergies confirmed
- Anesthesia safety check
- Check Pre Op Vitals
- Verbally confirmed Patient name, site and procedure
- Confirm Sterility
- Antibiotic prophylaxis given
- Post-operative vitals and assessment
Checklist after Surgery
- Check Counts
- Record procedure findings and steps
- Label specimen
- Signature of all members of the operating team: Surgeon, Anesthesiologist, Nursing Staff
- Patient observed for appropriate time
- Vitals and Patient assessment at discharge
- Post op orders explained
- Follow up appointment fixed