<asp:Table ID="Table1" CellPadding="15" CellSpacing="0" HorizontalAlign="Center" GridLines="Both" runat="server">
<asp:TableRow CssClass="alt2">
<asp:TableCell>1</asp:TableCell>
<asp:TableCell>Informed consent signed by patient/designee and physician</asp:TableCell>
<asp:TableCell>
<asp:RadioButtonList ID="RadioButtonList1" repeatdirection="Vertical" runat="server">
<asp:ListItem Value="Yes"></asp:ListItem>
<asp:ListItem Value="No"></asp:ListItem>
</asp:RadioButtonList>
<asp:RequiredFieldValidator ID="RequiredFieldValidator1" runat="server" ControlToValidate="RadioButtonList1" ErrorMessage="* Required"></asp:RequiredFieldValidator>
</asp:TableCell>
</asp:TableRow>
<asp:TableRow CssClass="alt">
<asp:TableCell>2</asp:TableCell>
<asp:TableCell><b>History & Physical - Contains the following:</b><br />Chief complaint, history of present illness heart/lung assessment</asp:TableCell>
<asp:TableCell>
<asp:RadioButtonList ID="RadioButtonList2" repeatdirection="Vertical" runat="server">
<asp:ListItem Value="Yes"></asp:ListItem>
<asp:ListItem Value="No"></asp:ListItem>
</asp:RadioButtonList>
<asp:RequiredFieldValidator ID="RequiredFieldValidator2" runat="server" ControlToValidate="RadioButtonList2" ErrorMessage="* Required"></asp:RequiredFieldValidator>
</asp:TableCell>
</asp:TableRow>
<asp:TableRow CssClass="alt2">
<asp:TableCell>3</asp:TableCell>
<asp:TableCell><br /><b>History & Physical - Meets one of the following criteria:</b><br />Signed/dated within 24 hrs of addmision<br />Less than 30 days old with update note/date/signature or progress note within 24 hrs?</asp:TableCell>
<asp:TableCell>
<asp:RadioButtonList ID="RadioButtonList3" repeatdirection="Vertical" runat="server">
<asp:ListItem Value="Yes"></asp:ListItem>
<asp:ListItem Value="No"></asp:ListItem>
</asp:RadioButtonList>
<asp:RequiredFieldValidator ID="RequiredFieldValidator3" runat="server" ControlToValidate="RadioButtonList3" ErrorMessage="* Required"></asp:RequiredFieldValidator>
</asp:TableCell>
</asp:TableRow>
<asp:TableRow CssClass="alt">
<asp:TableCell>4</asp:TableCell>
<asp:TableCell><b>"TIME OUT" performed & includes the following:</b><br />Confirmation of identity, side/site, consent form, procedure, need for abx/fluids, safety precautions when applicable</asp:TableCell>
<asp:TableCell>
<asp:RadioButtonList ID="RadioButtonList4" repeatdirection="Vertical" runat="server">
<asp:ListItem Value="Yes"></asp:ListItem>
<asp:ListItem Value="No"></asp:ListItem>
</asp:RadioButtonList>
<asp:RequiredFieldValidator ID="RequiredFieldValidator4" runat="server" ControlToValidate="RadioButtonList4" ErrorMessage="* Required"></asp:RequiredFieldValidator>
</asp:TableCell>
</asp:TableRow>
<asp:TableRow CssClass="alt2">
<asp:TableCell>5</asp:TableCell>
<asp:TableCell><b>Site Marking</b> - Operative site marked</asp:TableCell>
<asp:TableCell>
<asp:RadioButtonList ID="RadioButtonList5" repeatdirection="Vertical" runat="server">
<asp:ListItem Value="Yes"></asp:ListItem>
<asp:ListItem Value="No"></asp:ListItem>
<asp:ListItem Value="N/A"></asp:ListItem>
</asp:RadioButtonList>
<asp:RequiredFieldValidator ID="RequiredFieldValidator5" runat="server" ControlToValidate="RadioButtonList5" ErrorMessage="* Required"></asp:RequiredFieldValidator>
</asp:TableCell>
</asp:TableRow>
<asp:TableRow CssClass="alt">
<asp:TableCell>6</asp:TableCell>
<asp:TableCell>Anesthesia assessment performed?</asp:TableCell>
<asp:TableCell>
<asp:RadioButtonList ID="RadioButtonList6" repeatdirection="Vertical" runat="server">
<asp:ListItem Value="Yes"></asp:ListItem>
<asp:ListItem Value="No"></asp:ListItem>
<asp:ListItem Value="N/A"></asp:ListItem>
</asp:RadioButtonList>
<asp:RequiredFieldValidator ID="RequiredFieldValidator6" runat="server" ControlToValidate="RadioButtonList6" ErrorMessage="* Required"></asp:RequiredFieldValidator>
</asp:TableCell>
</asp:TableRow>
<asp:TableRow CssClass="alt2">
<asp:TableCell>7</asp:TableCell>
<asp:TableCell>Are all medications, medication containers or other solutions labeled?</asp:TableCell>
<asp:TableCell>
<asp:RadioButtonList ID="RadioButtonList7" repeatdirection="Vertical" runat="server">
<asp:ListItem Value="Yes"></asp:ListItem>
<asp:ListItem Value="No"></asp:ListItem>
<asp:ListItem Value="N/A"></asp:ListItem>
</asp:RadioButtonList>
<asp:RequiredFieldValidator ID="RequiredFieldValidator7" runat="server" ControlToValidate="RadioButtonList7" ErrorMessage="* Required"></asp:RequiredFieldValidator>
</asp:TableCell>
</asp:TableRow>
<asp:TableRow CssClass="alt">
<asp:TableCell>8</asp:TableCell>
<asp:TableCell>Is immediate physician's post op note present?</asp:TableCell>
<asp:TableCell>
<asp:RadioButtonList ID="RadioButtonList8" repeatdirection="Vertical" runat="server">
<asp:ListItem Value="Yes"></asp:ListItem>
<asp:ListItem Value="No"></asp:ListItem>
</asp:RadioButtonList>
<asp:RequiredFieldValidator ID="RequiredFieldValidator8" runat="server" ControlToValidate="RadioButtonList8" ErrorMessage="* Required"></asp:RequiredFieldValidator>
</asp:TableCell>
</asp:TableRow>
<asp:TableRow CssClass="alt2">
<asp:TableCell>9</asp:TableCell>
<asp:TableCell>Is the post op note completed and to include date, time, and signature?</asp:TableCell>
<asp:TableCell>
<asp:RadioButtonList ID="RadioButtonList9" repeatdirection="Vertical" runat="server">
<asp:ListItem Value="Yes"></asp:ListItem>
<asp:ListItem Value="No"></asp:ListItem>
</asp:RadioButtonList>
<asp:RequiredFieldValidator ID="RequiredFieldValidator9" runat="server" ControlToValidate="RadioButtonList9" ErrorMessage="* Required"></asp:RequiredFieldValidator>
</asp:TableCell>
</asp:TableRow>
</asp:Table>
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