Minor surgery lists can be hectic, but the Care Quality Commission (CQC) still expects evidence that every patient receives the same safe, consented, well-documented experience. A per-patient checklist keeps your team aligned with the NHS England Directed Enhanced Service (DES) for minor surgery, the Health and Social Care Act 2008 infection prevention requirements, the National Standards of Healthcare Cleanliness 2025 (treating the treatment room at the right cleanliness risk rating for invasive outpatient care), and the spirit of the World Health Organization surgical safety checklist—scaled to everyday general practice.
Use this ready-to-run checklist to brief staff, assure patients, and record the controls CQC inspectors look for. Adapt the headings for your own electronic clinical system or laminated theatre prompt.
Tip: Treat this as a gold-standard prompt sheet. Flex the depth depending on the complexity of the procedure and the size of your team—simple shave biopsies need lighter touch than cyst excisions or vasectomies.
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Before the patient arrives
Confirm the booked procedure, clinician credentials, and that the usual assistant or chaperone is available (or arrange an alternative).
Prepare the treatment room: complete the daily cleanliness log or 5-star display update (noting the cleanliness risk rating your practice uses for minor surgery), wipe touchpoints with a chlorine-based detergent (1,000ppm available chlorine), replace couch roll, restock PPE, and set out spill kits; check sharps bin position and that drugs, dressings, and consumables are in date.
Run quick safety checks: defibrillator on charge, anaphylaxis kit and oxygen pressure within range, suction tested if used.
Note any environmental readings your infection prevention and control (IPC) risk assessment requires (e.g., room temperature or ventilation tick box) and escalate only if outside the agreed limit.
Lay out sterile packs, single-use consumables, and local anaesthetic within expiry; you can capture batch numbers directly in the patient record later.
Review safeguarding flags, infection risks (e.g., MRSA status), anticoagulation plans, and allergies in the record.
Ensure consent discussion notes are current (verbal consent same day, written consent within the locally agreed timeframe).
On patient arrival
Verify patient identity using three identifiers (full name, date of birth, address) and match to the booked procedure.
Reconfirm consent, including risks, benefits, alternatives, and right to withdraw; offer a chaperone and record acceptance or decline.
Check the surgical site marking where applicable; confirm no contraindications such as active infection or unstable observations.
Confirm anticoagulation management (e.g., last warfarin dose, INR result) and diabetes considerations (fasting status, blood glucose).
Ensure the patient has eaten or fasted according to protocol, and confirm transport arrangements post-procedure.
Immediately before incision
Pause with your assistant for a quick run-through: confirm patient identity, procedure, site, and any anticipated issues (e.g., bleeding risk, need for histology).
Perform a final equipment check: ensure lighting, sterile field integrity, sharps tray position, and PPE are set. If you use diathermy, confirm settings; otherwise make sure cautery alternatives are ready.
Verify availability of histology pots, labeling supplies, and pathology request forms; pre-complete patient identifiers.
Review safety-critical medications (adrenaline doses, local anaesthetic maximums based on weight) and double-check calculations where applicable.
Open your preferred documentation template in the clinical system so details and SNOMED codes are captured in real time.
After the procedure
Inspect the wound, apply dressing, and provide written aftercare specific to the procedure (e.g., suture removal timeframe, warning signs).
Record the procedure immediately: site, method, anaesthetic batch and expiry, staff present, complications, estimated blood loss (if relevant), and specimens taken.
Label specimens in front of the patient, complete pathology requests, and arrange courier collection or drop-off log.
Dispose of sharps safely, clear clinical waste into colour-coded streams, refresh the cleanliness display if used, and wipe down high-touch surfaces before the next patient.
Update recall tasks: suture removal appointments, histology chase reminders, and safety-netting calls if required.
Closing the patient episode
Code the procedure correctly to ensure DES payments and audit trails; attach clinical photos if your policy requires.
File consent forms, chaperone records, and post-operative instruction leaflets to the patient record.
Document patient understanding of aftercare, including contact pathways for red flag symptoms and emergency escalation.
If anything unexpected happened, schedule a short debrief or log it in your significant event system while details are fresh.
Tick off the checklist, capture the clinician’s signature, and store the completed checklist for at least the retention period defined in your records management policy.
Keeping the checklist live
Audit compliance quarterly, sampling cases to confirm every field is complete and traceable.
Update content when guidance changes—monitor NHS England DES specifications, the National Standards of Healthcare Cleanliness 2025 (including any updates to the cleanliness risk rating matrix), National Infection Prevention and Control Manual updates, and Medicines and Healthcare products Regulatory Agency (MHRA) device alerts.
Train the whole minor surgery team annually, including bank staff, on the checklist flow and immediate anaphylaxis response.
Encourage staff to suggest improvements after each session; integrate feedback into your patient safety and quality meeting actions.
Disclaimer: This article is for informational purposes only and reflects understanding as of the publication date. It does not constitute legal, financial, or medical advice. Practices should consult the latest guidance from the CQC, NHS England, MHRA, and relevant professional bodies for specific circumstances.