Surgery Checklist

Please review your surgical checklist to ensure that necessary arrangements are made, equipment is available, paperwork is complete and your child is ready for surgery at Shriners Hospitals for Children – Northern California. Have your checklist completed and readily available for use during your preoperative phone call. Bring your list with you on surgery day.

Click here for a printable version of the Surgery Information and Checklist.

Surgery Checklist

Are you the biological parents and able to sign surgical consents?

YES or NO – Contact your Social Worker to discuss your individual situation; special documents or even a court order for surgery may be required.

Have you provided custody documents such as divorce decree, custody agreement or foster care agreement?

YES or NO – Send your documents to your Social Worker as soon as possible.

Are you willing to consent to a blood transfusion even if one is very unlikely?

YES or NO – Contact your RN Care Manager to discuss.

Will your child require medical clearance for surgery?

YES or NO – Your LVN/RN team members will ask you several health questions to determine if we require clearance from other specialists that provide care for your child. We will need the medical records from those doctors as well as test reports. Your child may require a consultation appointment with our Shriners pediatrician or pediatric anesthesiologist prior to going forward with surgery. This is necessary to ensure the safety of your child during surgery.

Are all of your required tests complete (MRI, CT, EMG) and does Shriners have a copy?

YES or NO – If you do not know, contact your RN Care Manager

Within Three Weeks of Surgery

Is your child free of recent illness or health change?

YES or NO – If No: Call the Admission’s Department at 916-453-2204

Have you planned for time off work and submitted FMLA (Family Medical Leave Act) or Paid Family Leave forms?

YES or NO – We require a minimum of 2 weeks to complete forms – forward to Health Information Department (Medical Records) for processing: Phone: 916-453-2164 FAX: 916-453-2355

Have you arranged for transportation and lodging if needed?

YES or NO – For a referral, call the Lodging & Transportation Coordinator at 916-453-2095, referrals are NOT reservations. Rooms for Ronald McDonald House and Kiwanis are not guaranteed; have a back-up plan.

Have you notified your child’s school for a planned absence and sent any required forms to us for completion?

YES or NO – Send required forms to our Medical Records Department no less than 2 weeks before surgery.

Is your preoperative appointment either scheduled or completed?

YES or NO – Call your RN Care Manager

If physical therapy or occupational therapy is required, have you verified that your primary care provider made the referral or that your CCS (California Children’s Services) case is open?

YES or NO – Call your RN Care Manager

Within Two Weeks of Surgery

If your doctor recommends DME (Durable Medical Equipment) – wheelchair, walker, commode, raised toilet seat, etc., have you confirmed delivery with the vendor?

YES or NO – If you have questions, contact your Care Manager or Social Worker.

Have you considered that you will not be allowed to have artificial nails, nail polish or jewelry? Pierced body jewelry must also be removed.

YES or NO – Consider timing of nail care and new piercings.

1 Week Before Surgery

Has your child stopped taking blood thinners? Blood thinners are often but not always stopped before surgery.

YES or NO – If taking ASPIRIN products, ask your doctor IF you should stop and WHEN.

Have you stopped taking anti-inflammatory medications 7 days prior to surgery unless instructed by your doctor? These include Motrin, Advil, Aleve, and Naproxen, Tylenol is ok.

YES or NO – Call your RN Care Manager to discuss.

Have you notified your physician if your child is taking herbal supplements or teas?

YES or NO – Contact your RN Care Manager to discuss.

Day Before Surgery

You will get a phone call to review this checklist and to receive arrival and fasting instructions. Please ensure that we have accurate contact numbers.

  • Shower or bathe the night before or morning of surgery. Wash hair. Check for lice.
  • Remove nail polish, artificial nails, jewelry, including ALL piercings.
  • Check and follow the fasting guidelines provided during the surgery preparation phone call
  • Plan to take all usual prescription medications on the morning of surgery with a small sip of water, unless specifically told otherwise by the surgeon or anesthesiologist
  • Confirm your transportation arrangements to and from the hospital
  • Parent or legal guardian with authority to consent is accompanying the child to the hospital unless other arrangements have been made ahead of time.

Pack The Following

  • Loose and comfortable clothes that are easy to get on or may need to go over a cast or brace
  • Current immunization record
  • Official copy of birth certificate (not hospital issued)- if not already on file
  • All medications in their ORIGINAL labeled bottles
  • Car seat
  • Health insurance card
  • Your child’s comfort toy or blanket and this check list

Day of Surgery

FASTING GUIDELINES (NPO)

  • After 12:00 midnight the night before surgery:
    • No solid foods
    • No gum, candy or mints
    • No liquid foods (applesauce, pudding, milk)
  • Stop infant/toddler formula 4 hours prior to your ARRIVAL time
  • Stop breast milk 2 hours prior to your ARRIVAL time
  • Anesthesia allowed CLEAR liquids are encouraged until 1 hour before your ARRIVAL time
  • Anesthesia allowed CLEAR liquids are ONLY water, Pedialyte, apple juice and Gatorade.

FOR SAFETY REASONS IT IS VERY IMPORTANT TO FOLLOW FASTING GUIDELINES EXACTLY. IF NOT, YOUR CHILD’S SURGERY COULD BE DELAYED OR CANCELLED!

Patient Referral

916-453-2191
916-453-2111 (Emergency Referral)
916-453-2395 (fax)
referrals.ncal@shrinenet.org

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