Appendix MM – Surgery Time Out Form

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Instructions for Utilizing the SSM Dermatology Surgery Time-Out Form
Purpose:
The SSM Dermatology Surgery Time-Out Form is designed to ensure patient safety and procedural
accuracy by requiring multiple confirmations at various stages of the surgery. This form is
particularly crucial for Mohs surgery, where multiple layers are involved and patients may leave the
room in between Mohs stages.
Steps to Complete the Time-Out Form

1. Patient Identification
   • Name: Enter the patient’s full name (to be completed by MA).
   • Date of Birth: Enter the patient’s date of birth (to be completed by MA).
2. Procedure Identification
   • Name of Surgeon(s): List the names of the surgeon(s) performing the procedure. If you are
   participating in the procedure, please write your name on the timeout sheet.
   • Team Member(s): List all team members involved in the procedure.
   • Procedure: Specify the exact procedure being performed (e.g., Mohs surgery - to be
   completed by MA).
   • Procedure Site: Indicate the specific site on the patient’s body where the procedure will
   occur (to be completed by MA).
3. Initial Confirmations
   • Identification of Patient, Procedure, and Site:
   • The surgeon and a team member must both confirm the patient’s identity by
   checking the patient’s name and date of birth against the form.
   • The surgeon and a team member must confirm the procedure to be performed,
   ensuring it matches the patient’s consent and medical records.
   • The surgeon and a team member must confirm the exact site of the procedure,
   ensuring it matches the patient’s consent and medical records.
   • The surgeon column may be filled out by the attending physician, the
   surgical fellow, or the dermatology resident. The team member column may
   be filled out by any of the above or a medical assistant.
   • Document the time of this confirmation.
   • Patient Confirmation of Site (Initials):

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• Ask the patient to initial this section to confirm the site of the procedure after the
completion of the timeout. This step involves the patient directly in the verification
process.
4. Mohs Surgery Additional Layer and Reconstruction Confirmations
• For each additional layer of Mohs surgery as well as the Mohs reconstruction, both the
surgeon and a team member must confirm the patient’s full name and date of birth and
record this on the timeout sheet.
• Document the time of this confirmation.
Important Notes:
• Accuracy: Ensure all information is accurate and legible.
• Patient Involvement: Engage the patient in the verification process by having them initial
the site confirmation.
• Consistency: Follow the same process for each layer in Mohs surgery to maintain
consistency and reduce errors.
• Documentation: Properly document the time of each confirmation to maintain a clear and
accurate record of the procedure.
Conclusion:
Following these instructions will help ensure the safety and accuracy of dermatological surgical
procedures. Always double-check each step and involve your team to maintain the highest
standards of patient care.
If you have any questions or need further clarification, please do not hesitate to ask your attending
physician or the surgical fellow.