PROCEDURE CHECKLIST

1. TOPICAL APPLICATION TO SKIN

TICK MARK (YES OR NO)

STEPS YES NO COMMENTS

1. Confirms the patient’s identity by checking the identification band,

patient’s medication record and the doctor’s order in chart.
2. Arrange the articles.

3. Explain the procedures to the patient.

4. Wash hands and wear gloves if required.

5. Help patient to assume comfortable position and expose the area to

be treated.
6. Clean the skin area with soap and warm water and change the gloves
if soiled.
7. Open the container and place the lid/cap upside down.

8. Apply the medication using a sterile applicator or sterile gloves.

9. Apply medication to the affected area with long smooth stroke and
follow the direction of hair growth.
10. Cover the area with dressing, if ordered.

11. Reposition the patient for comfort and safety.

12. Removes gloves and wash hands.

13. Document the medication applied, the site and patient response to
medicine.

14. Discard the waste as per biomedical waste management.

 2. TOPICAL APPLICATION TO MOUTH

STEPS YES NO COMMENTS

1. Confirms the patient’s identity by checking the identification band,

patient’s medication record and the doctor’s order in chart.
2. Arrange the articles.

3. Explain the procedures to the patient.

4. Wash hands and wear gloves if required.

5. Help patient to assume comfortable position.

6. Place a towel around the neck.

7. Squeeze the medication into the sterile applicator.

8. Tell the patient to open the mouth.

9. Apply the medicine to mouth using the applicator.

10. Replace the applicator in the paper bag.

11. Replace the towel and kidney tray.

12. Recap the medicine and put in the medicine cupboard.

13. Wash hands.

14. Records the procedure with date and time when the medication
applied.
 3. THROAT GARGLE

STEPS YES NO COMMENTS

1. Check the patient identification and case sheet for physician’s order.

2. Access the condition of the patient.

3. Arrange the articles.

4. Explain the procedures to the patient.

5. Advise the patient to tolerate a mouthful of the solution and not to

swallow.
6. Instruct to tilt head backwards and make gargling sound.

7. Instruct to spit out the gargled solution into the kidney tray.

8. Continue gargling with mouthful of warm solution.

9. Make the patient comfortable.

10. Record the procedure.

11. Wash and dismantle all articles. Discard wastes as per Biomedical
Waste Management
 4. THROAT PAINTING

STEPS YES NO COMMENTS

1. Check the patient identification and case sheet for physician’s order.

2. Arrange the articles.

3. Assess the condition of the patient.

4. Explain the procedure to the patient.

5. Position the patient to sit on a chair and tilt his head backwards.

6. Place a towel around the neck.

7. Wash hands.

8. Adjust the spot light to visualize the throat clearly.

9. Take the medicine on cotton applicator.

10. Ask the patient to say “aha: so as to open the mouth fully and to
reduce anxiety to save time and place the tongue depressor over his
tongue and apply slight pressure downwards.
11. Paint the throat (tonsils and back of the pharynx) quickly using
circular movement. Allow the patient to breath in between.
12. Record the procedure with date and time.

13. Wash and dismantle all articles. Discard wastage as per Biomedical
Waste management.