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Note: Documents marked with "PDF" (portable document format) are readable with Acrobat Reader, available here for free. Documents marked with "XLS" (Excel spreadsheet) are readable with Microsoft Excel or any spreadsheet software.

Forms From 2014

"Pre-Anesthesia Evaluation Form"
Courtesy of Anesthesia Professionals Inc.

 Size: 1mb
 Type: PDF

"Colonoscopy Prep Fact Sheet"
Courtesy of Mountain States Medical Group

 Size: 312kb
 Type: PDF

"Morcellation Consent Form"
Courtesy of Vicki V. Schultz, RN, CASC

 Size: 368kb
 Type: PDF

"Immediate-Use Steam Sterilization (IUSS) Audit Check Sheet"
Courtesy of Seavey Healthcare Consulting

 Size: 27kb
 Type: PDF

"OR Cleaning/Terminal Cleaning Checklist"
Courtesy of Kathleen Pressimone, RN, CNOR, and Jeanne Sedgwick, RN, MSN, CNOR

 Size: 352kb
 Type: PDF

"What Do You Know About...Pre-op CHG Showers" References
Courtesy of Outpatient Surgery Magazine

 Size: 27kb
 Type: PDF

"Why Scrub When You Can Rub?" References
Courtesy of Janet P. Haas, RN, DNSc, CIC

 Size: 86kb
 Type: PDF

Forms From 2013

Ideas That Work: Staff Appreciation
Courtesy of Chuck Knight RN, BSN, CNOR

 Size: 540kb
 Type: PDF

"What's Inside Your Credentialing Files"
Courtesy of Gordon C. Merrick, MBA

 Size: 762kb
 Type: PDF

"6 Glaucoma Treatment Options"
Courtesy of Outpatient Surgery Magazine

 Size: 340kb
 Type: PDF

"Hand Hygiene Monitoring Tool"
Courtesy of Carol Cappella, RN, MSN, CNOR

 Size: 59kb
 Type: PDF

"Which Skin Prep is Best"
Courtesy of Outpatient Surgery Magazine

 Size: 407kb
 Type: PDF

Ideas That Work: Patient Transfer Form
Courtesy of Linda W. Frix, RN, BSN, CAPA

 Size: 327kb
 Type: PDF

Ideas That Work: PONV Risk Scoring Tool
Courtesy of Dee Weigel, RN, BS

 Size: 40kb
 Type: XLS

Ideas That Work: Pre-Op Patient Assessment
Courtesy of Katie Keller-Guglietta, RN

 Size: 148kb
 Type: PDF

Ideas That Work: Keep Long Shifts in Check
Courtesy of Timothy Flint, MS, CRNA

 Size: 179kb
 Type: PDF

"How Well Do You Know Your Microorganisms?"
Courtesy of Ann Marie Pettis, RN, BSN, CIC

 Size: 129kb
 Type: PDF

Forms From 2012

Difficult Airway Letter
Courtesy of Heidi Koenig, MD

 Size: 68kb
 Type: PDF

"Your Guide to Obstructive Sleep Apnea Patients"
Courtesy of Girish P. Joshi, MB BS, MD, FFARCSI

 Size: 324kb
 Type: PDF

"Are You Sure Your Surgical Instruments Are Sterile?"
Courtesy of Linda R. Greene, RN, MPS, CIC

 Size: 318kb
 Type: PDF

"Surface Disinfection: How Do You Rate?"
Courtesy of Ann Marie Pettis, RN, BSN, CIC

 Size: 324kb
 Type: PDF

Customized Discharge Instructions
Courtesy of Kathryn Farrell, MSN, RN, and Bruce Kloss, BSN, RN, CNOR

 Size: 70kb
 Type: PDF

"Know Your Wipes, Mops & Sprays" References
Courtesy of Ann Marie Pettis, RN, BSN, CIC

 Size: 33kb
 Type: PDF

February Crossword Puzzle Solution
Courtesy of Outpatient Surgery Magazine

 Size: 18kb
 Type: PDF

Forms From 2011

10 Look-Alike/Sound-Alike Drugs for Surgical Facilities
Courtesy of Sheldon S. Sones, RPh, FASCP

 Size: 33kb
 Type: PDF

Discharge Criteria
Courtesy of Surgical Center of DuPage Medical Group

 Size: 28kb
 Type: PDF

New Allergy Process
Courtesy of West Hartford Surgery Center

 Size: 36kb
 Type: PDF

What to Expect After Throat Surgery
Courtesy of St. John's Clinic: Ear, Nose, & Throat

 Size: 37kb
 Type: PDF

"14 Irrefutable Reasons to Eleminate Surgical Smoke" References
Courtesy of Kay Ball, PhD, RN, CNOR, FAAN

 Size: 28kb
 Type: PDF

Letter of Compliance
Courtesy of www.StopNarcoticTampering.org

 Size: 57kb
 Type: PDF

Crash Cart Drawer-by-Drawer Breakdown
Courtesy of Dan Simonson, CRNA, MHPA, Spokane Eye Surgery Center

 Size: 60kb
 Type: PDF

Regional Anesthesia Procedure Superbill & Procedure Note
Courtesy of Northwest Ambulatory Surgery Center

 Size: 70kb
 Type: PDF

"Wipe Out the Confusion Over Surface Disinfection" References
Courtesy of Donna Nucci, RN, BSN, CIC

 Size: 28kb
 Type: PDF

Peripheral Nerve Blockade Procedure Note
Courtesy of Jackson Memorial Hospital

 Size: 819kb
 Type: XLS

Receiving and Returning Borrowed Surgical Instrument Tray from Other Hospitals — Process Map
Courtesy of Randy Hillman

 Size: 16kb
 Type: PDF

Tips to Make Sure Your Patients Register Online
Courtesy of Specialty Surgical Center

 Size: 728kb
 Type: PDF

"Infection Prevention: How to Handle Patients with MRSA" References
Courtesy of Peggy SaBell, RN, MS, CIC

 Size: 158kb
 Type: PDF

Malignant Hyperthermia Response Cards
Courtesy of Ponte Vedra Plastic Surgery

 Size: 69kb
 Type: PDF

Patient Satisfaction Survey
Courtesy of Bone and Joint Surgery Center of Novi

 Size: 305kb
 Type: PDF

Anesthesia Charge Sheet
Courtesy of Outpatient Surgery Magazine

 Size: 38kb
 Type: PDF

Forms From 2010

Safety Orientation Checklist and Guideline
Courtesy of Kristie Jolliff, RN, BSN, CNOR, RNFA

 Size: 23kb
 Type: PDF

What Your Reprocessing Techs Need to Know
Courtesy of Outpatient Surgery Magazine

 Size: 101kb
 Type: PDF

Employee Counseling & Improvement Plan
Courtesy of Ann Geier, RN, MS, CNOR, CASC

 Size: 72kb
 Type: PDF

Medication Errors Checklist: Prevention and Response
Courtesy of Outpatient Surgery Magazine

 Size: 155kb
 Type: PDF

STOP-BANG Questionnaire
Courtesy of Outpatient Surgery Magazine

 Size: 29kb
 Type: PDF

Pain Fee Table
Mowles Medical Practice Management, LLC

 Size: 173kb
 Type: XLS

Ideas That Work: Nerve Pathways
Courtesy of Outpatient Surgery Magazine

 Size: 1Mb
 Type: PDF

Answers to Personal Protective Equipment Quiz
Courtesy of Donna Nucci, RN, BSN, CIC

 Size: 35kb
 Type: PDF

Sterilizer Failure Checklist
Courtesy of Outpatient Surgery Magazine

 Size: 68kb
 Type: PDF

Natural Disaster Checklist: Hurricane Preparedness
Courtesy of Outpatient Surgery Magazine

 Size: 96kb
 Type: PDF

Perioperative Block Record
Courtesy of Cathy Rice, MD

 Size: 68kb
 Type: PDF

Sample Product Evaluation Form
Courtesy of University of Mississippi Health Care

 Size: 145kb
 Type: PDF

The "9" Count
Courtesy of Outpatient Surgery Magazine

 Size: 80kb
 Type: PDF

Fire Checklist
Courtesy of Outpatient Surgery Magazine

 Size: 127kb
 Type: PDF

Example of a Hand Hygiene Monitoring Tool
Courtesy of Outpatient Surgery Magazine

 Size: 224kb
 Type: PDF

TASS Prevention Suggestions
Courtesy of Outpatient Surgery Magazine

 Size: 52kb
 Type: PDF

Crew Resource Management Pre-Procedure Checklist
Courtesy of Memorial Hospital, Pembroke, Fla.

 Size: 1.5Mb
 Type: PDF

Post-op Ophthalmic Instrument Decontamination Checklist
Courtesy of WakeMed

 Size: 53kb
 Type: PDF

Intraoperative Ophthalmic Checklist
Courtesy of Outpatient Surgery Magazine

 Size: 47kb
 Type: PDF

OR Strength Exercises
Courtesy of WakeMed

 Size: 849kb
 Type: PDF

SSI Outbreak Checklist
Courtesy of Outpatient Surgery Magazine

 Size: 34kb
 Type: PDF

Going Home from the Hospital Following a Nerve Block
Courtesy of Kernan Orthopaedics and Rehabilitation, University of Maryland Medica, Baltimore, MD

 Size: 27kb
 Type: PDF

DonJoy IceMan Post Op Instructions
Courtesy of Kernan Orthopaedics and Rehabilitation, University of Maryland Medica, Baltimore, MD

 Size: 350kb
 Type: PDF

Post-Operative Discharge Instructions for Cervical Spine Surgery
Courtesy of Diagnostic and Interventional Surgical Center

 Size: 403kb
 Type: PDF

Post-Operative Discharge Instructions for Lumbar Spine Surgery
Courtesy of Diagnostic and Interventional Surgical Center

 Size: 403kb
 Type: PDF

Prophylactic Antibiotic Regimen Selection for Surgery
Courtesy of Outpatient Surgery Magazine

 Size: 63kb
 Type: PDF

"Legal Update: ASC Hospital Transfer Requirements Summary, by State" References
Courtesy of Outpatient Surgery Magazine

 Size: 35kb
 Type: PDF

Forms From 2009

Sharps Safety Form
Courtesy of Outpatient Surgery Magazine

 Size: 115kb
 Type: PDF

Cataract Cost Sheet
Courtesy of Outpatient Surgery Magazine

 Size: 64kb
 Type: XLS

"What Do You Know About Regional Anesthesia" References
Courtesy of Outpatient Surgery Magazine

 Size: 46kb
 Type: PDF

"What Do You Know About Products Treated With Antimicrobials" References
Courtesy of Outpatient Surgery Magazine

 Size: 28kb
 Type: PDF

"Materials That Help Reduce Pressure Injuries" References
Courtesy of Outpatient Surgery Magazine

 Size: 23kb
 Type: PDF

Infection Control Surveyor Worksheet
Courtesy of Outpatient Surgery Magazine

 Size: 234kb
 Type: PDF

"What Do You Know About Skin Preparation" References
Courtesy of Outpatient Surgery Magazine

 Size: 27kb
 Type: PDF

"Protect Yourself from Head to Toe" References
Courtesy of Outpatient Surgery Magazine

 Size: 25kb
 Type: PDF

Patient Hand-off Checklist
Courtesy of Charlene DiNobile, RN, Med, CNOR, CNAA, CST

 Size: 24kb
 Type: PDF

Perioperative Skin Assessment Tool
Courtesy of Christine Kennedy, RN, BSN, MA, CNOR

 Size: 42kb
 Type: PDF

Biopsy Report Form Letter to Patients
Courtesy of Endoscopy Center of Colorado Springs

 Size: 37kb
 Type: PDF

"Recipe for a Successful Safety Scalpel Trial" References
Courtesy of Outpatient Surgery Magazine

 Size: 23kb
 Type: PDF

"What Do You Know About...Vascular Access" References
Courtesy of Outpatient Surgery Magazine

 Size: 28kb
 Type: PDF

"What Do You Know About...Pre-op CHG Showers" References
Courtesy of Outpatient Surgery Magazine

 Size: 27kb
 Type: PDF

Forms From 2008

Perioperative Block Record
Courtesy of Cathy Rice, MD

 Size: 68kb
 Type: PDF

Making Time for Blocks References
Courtesy of Michael F. Mulroy, MD

 Size: 67kb
 Type: PDF

Financial Management of the Center
Courtesy of Outpatient Surgery Magazine Editors

 Size: 81kb
 Type: PDF

Pre-op Form 1: Patient Questionnaire
Courtesy of Truvista Surgery Center

 Size: 97kb
 Type: PDF

Pre-op Form 2: Medication Form
Courtesy of Truvista Surgery Center

 Size: 67kb
 Type: PDF

Forms From 2007

3 Steps to Right-sizing Your Suture Stock
Courtesy of Robert Schaff

 Size: 683kb
 Type: PDF

Why Scrub When You Can Rub? References
Courtesy of Janet P. Haas, RN, DNSc, CIC

 Size: 86kb
 Type: PDF

What's Your Consciousness Telling You? References
Courtesy of Colletta A. Richards, MD

 Size: 86kb
 Type: PDF

Diet Sheet
Courtesy of Denise Kohler, RN, BSN, MSN

 Size: 72kb
 Type: PDF

Prep Instructions
Courtesy of Denise Kohler, RN, BSN, MSN

 Size: 82kb
 Type: PDF

Contract Checklist
Courtesy of Alicia R. Cooper, Little Rock, Arkansas

 Size: 99kb
 Type: PDF

Eye Preps: When You Can't Use Povidone Iodine
Courtesy of Jean Hill, RN, MSN, CRNO and Lisa (Mary) Hill, RN, BSN

 Size: 107kb
 Type: PDF

The Essentials of Competency Programs for Ambulatory Surgery and Hospital Outpatient Settings
Courtesy of Dawn Q. McLane, RN, MSA, CASC, CNOR

 Size: 98kb
 Type: PDF

Forms From 2006

Surgical Pricing Schedule
Courtesy of Jay Schorr of Advanced Cosmetic Laser Center

 Size: 75kb
 Type: XLS

"How to Head off Deep Vein Thrombosis" References, June 2006
Courtesy of Anita Johnston, RN, BSN, CNOR

 Size: 95kb
 Type: PDF

2006 Medicare Injection and Infusion Flowchart
Courtesy of Lolita M. Jones, RHIA

 Size: 17kb
 Type: PDF

Orthopaedic Discharge Form
Courtesy of Lacey Dyer, RN

 Size: 32kb
 Type: PDF

Sample Assignment of Benefits Form
Courtesy of MedBridge Development, LLC

 Size: 64kb
 Type: PDF

Safety References, May 2006
Courtesy of Scott DeBoer, RN, MSN, CEN, CCRN, CFRN

 Size: 105kb
 Type: PDF

Sample Provisions for Partnership Agreements
Courtesy of Scott Becker, JD, CPA and Alison Vratil Mikula, JD of McGuire Woods in Chicaco, Ill.

 Size: 110kb
 Type: PDF

"Busting 7 Back Injury Myths" and "Inside the Numbers" References, March 2006
Courtesy of Jamie Tessler, MPH

 Size: 111kb
 Type: PDF

Sample Surgeon Survey
Courtesy of Janice E. Rey, MP (ASCP), CIC, St. John Hospital and Medical Center, Detroit, MI

 Size: 71kb
 Type: PDF

Ambulatory Surgery: Surgical Site Infection Surveillance: Pt 1
Courtesy of Janice E. Rey, MP (ASCP), CIC, St. John Hospital and Medical Center, Detroit, MI

 Size: 72kb
 Type: PDF

Ambulatory Surgery: Surgical Site Infection Surveillance: Pt 2
Courtesy of Janice E. Rey, MP (ASCP), CIC, St. John Hospital and Medical Center, Detroit, MI

 Size: 77kb
 Type: PDF

Infection Control Construction/Renovation Monitoring Checklist
Courtesy of Janice E. Rey, MP (ASCP), CIC, St. John Hospital and Medical Center, Detroit, MI

 Size: 87kb
 Type: PDF

Infection Control Construction Permit
Courtesy of Janice E. Rey, MP (ASCP), CIC, St. John Hospital and Medical Center, Detroit, MI

 Size: 75kb
 Type: PDF

Unanticipated Care After Discharge From Ambulatory Surgical Facilities
Courtesy of The Patient Safety Authority

 Size: 489kb
 Type: PDF

January, 2006 Safety Column References
Courtesy of Joy L. Hawkins, MD

 Size: 82kb
 Type: PDF

Forms From 2005

Patient Surgery Cost Sheet
Courtesy of Betsy Sharp, Administrator, Orthopaedic Associates Surgery Center LLC in Augusta, Georgia

 Size: 94kb
 Type: PDF

Precertification for Surgery Form
Courtesy of Betsy Sharp, Administrator, Orthopaedic Associates Surgery Center LLC in Augusta, Georgia

 Size: 90kb
 Type: PDF

General Post-operative Guidelines for Patients with Known History of Obstructive Sleep Apnea Requiring Use of CPAP
Courtesy of Marjorie N. Blouin, RN and Shannon Magro, RN, Frederick Surgical Center, Frederick, Maryland

 Size: 93kb
 Type: PDF

PCC BMI/CPAP Protocol
Courtesy of Marjorie N. Blouin, RN and Shannon Magro, RN, Frederick Surgical Center, Frederick, Maryland

 Size: 88kb
 Type: PDF

Myths of Pediatric Anesthesia References
Courtesy of Zeev Kain, MD, MBA, Professor and Chief of Pediatric Anesthesiology, Yale University School of Medicine

 Size: 94kb
 Type: PDF

Vacation & Sick Leave Accrual and Utilitization
Courtesy of Kristine Bedford, RN, Clinical Director, Endoscopy Center of Marin, Greenbrae, California

 Size: 67kb
 Type: PDF

Adverse Incident Report
Courtesy of The American Society of Plastic Surgeons

 Size: 71kb
 Type: PDF

Penicillin Allergy Algorithm
Courtesy of Outpatient Surgery Magazine

 Size: 300kb
 Type: PDF

Adult Pre-Operative Antibiotic Physicians Order Form
Courtesy of Southwest Generat Hospital Center, Middleburg, Ohio

 Size: 420kb
 Type: PDF

Operating Room Par Levels
Courtesy of Beverly Kirchner, RN, BSN, CNOR, CASC

 Size: 89kb
 Type: PDF

Sample Narcotics Form
Courtesy of Kris Fisher, RN, CNOR, BSN, Turtle Creek Surgery Center

 Size: 85kb
 Type: PDF

Checklist for Adding a Service Line
Courtesy of Sharon Davis, RN, RVT

 Size: 81kb
 Type: PDF

July "Legal Update" References
Courtesy of Outpatient Surgery Editors

 Size: 89kb
 Type: PDF

Plastic Surgery Safety Checklist
Compiled by Contributing Editor Dianne Taylor

 Size: 112kb
 Type: PDF

NCMC/SPC Case Cart Quality Inspection Sheet
Courtesy of Jennifer L. Misajet, RN, BBA, CNOR: Director of Surgical Services, Western States Burn Center

 Size: 71kb
 Type: PDF

Initial Appeal Documentation
Courtesy of Deborah L. Mack, MSN, CASC, CNOR

 Size: 34kb
 Type: DOC

Sample EOC Plan
Courtesy of Nancy Burden, RN, MS, CPAN, CAPA

 Size: 134kb
 Type: DOC

Example Table of Contents for Administration Manuals
Courtesy of Nancy Burden, RN, MS, CPAN, CAPA

 Size: 90kb
 Type: PDF

Coding the Most Common Colonoscopies
Courtesy of Stephanie Ellies, RN, CPC

 Size: 84kb
 Type: PDF

Sample Side-by-Side Surgical Lighting Trial Evaluation Form
Courtesy of Phyllis Rozema, BS, Borgess Hospital, Kalamazoo, Michigan

 Size: 101kb
 Type: PDF

March "Overcoming the Roadblocks to Regional Anesthesia" References
Courtesy of Outpatient Surgery Magazine

 Size: 82kb
 Type: PDF

Evaluating Skin Preps Pullout Full Version
Download by page:

  •  Page 1 (547kb)

  •  Page 2 (84kb)

  •  Page 3 (2.1Mb)

  •  Page 4 (74kb)

Courtesy of Outpatient Surgery Magazine

 Size: 2.8Mb
 Type: PDF

February "Fast Facts About Fast Track Anesthesia" References
Courtesy of Outpatient Surgery Magazine

 Size: 105kb
 Type: PDF

NCMC/SPC Case Cart Quality Inspection Sheet
Courtesy of Jennifer L. Misajet, RN, BBA, CNOR: Director of Surgical Services, Western States Burn Center

 Size: 71kb
 Type: PDF

Medicare Survey Checklist
Courtesy of Genesee Associates, Inc.

 Size: 101kb
 Type: PDF

Employee Human Resource File: Chart Order
Courtesy of Genesee Associates, Inc.

 Size: 71kb
 Type: PDF

Initial Medical Executive Committee/Board Meeting Surgery Center
Courtesy of Genesee Associates, Inc.

 Size: 84kb
 Type: PDF

Surgery Center Organizational Chart
Courtesy of Genesee Associates, Inc.

 Size: 50kb
 Type: PDF

Development Team Assignments / Time Line: Surgery Center
Courtesy of Genesee Associates, Inc.

 Size: 50kb
 Type: XLS

Forms From 2004

Medicare Program; Update of Ambulatory Surgical Center List of Covered Procedures
Courtesy of Department of Health and Human Services

 Size: 352kb
 Type: PDF

"If You're Thinking of Buying..." References
Courtesy of Outpatient Surgery Magazine

 Size: 90kb
 Type: PDF

Crash Cart Inventory Checklist
Courtesy of Progressive Surgical Solutions, LLC.

 Size: 56kb
 Type: PDF

Pain Management Fee Schedule
Courtesy of Mowles Medical Practice Management, LLC.

 Size: 100kb
 Type: PDF

Surgical Glove Evaluation
July, 2004 - 107kb - PDF

 Size: 100kb
 Type: PDF

Sample Man Hours/Case Worksheet
Courtesy of Caryl A. Serbin, RN, BSN, LHRN

 Size: 94kb
 Type: PDF

Sample Surgical Site Infection Tracking Form
Adapted from St. John's Mercy Medical Center Infection Control Department

 Size: 99kb
 Type: PDF

Professional Associations and Nursing Organizations
Courtesy of Ann Geier, RN, MS, CNOR

 Size: 94kb
 Type: PDF

Patient-Controlled Analgesia (PCA) Pump Safety Protocol
Courtesy of Institute for Safe Medication Practices (ISMP), Huntingdon Valley, Pa.

 Size: 68kb
 Type: PDF

Nurse Endoscopy Training Protocol
Courtesy of Alaska Native Medical Center, Anchorage, Alaska.

 Size: 64kb
 Type: PDF

Flexible Sigmoidoscopy Screening Protocol
Courtesy of National Naval Medical Center Division of Gastroenterology, Bethesda, Md.

 Size: 51kb
 Type: PDF

Index of Corporate Partners, Managers and Consultants

 Size: 82kb
 Type: PDF

A Sample Policy on Supply Pilfering
Courtesy of Jerrie Smith

 Size: 92kb
 Type: PDF

Provider-Specific Trends: Rennaissance and Baroque Artists Hospital
Courtesy of Siegel and Krohn, PC

 Size: 91kb
 Type: PDF

2004 Patient Safety Principles for Office-Based Surgery Utilizing Moderate Sedation/Analgesia, Deep Sedation/Analgesia, or General Anesthesia
Courtesy of American College of Surgeons

 Size: 79kb
 Type: PDF

The Fraud and Abuse Statute and Investor-Owned Ambulatory Surgery Centers
Courtesy of Scott Becker and Nicholas Harned

 Size: 666kb
 Type: PDF

4 Tips for Assessing Post-op Pain in Elderly Patients
Courtesy of M. McCaffrey and C. Pasero

 Size: 74kb
 Type: PDF

A Latex Allergy Patient Screening Questionnaire
Courtesy of Lauren Charous, MD

 Size: 78kb
 Type: PDF

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