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Eastern Visayas Regional Medical Center: Tacloban City, Philippines, 6500

This document is an instrument, sponge, and needle count sheet from the Eastern Visayas Regional Medical Center in Tacloban City, Philippines. It records information about a surgical procedure, including the patient's details, surgery type, start and end times, pre-operative and post-operative diagnoses, procedure performed, counts of instruments, sponges and needles used, and signatures of the medical staff involved.

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Marimiel Pagulayan
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205 views1 page

Eastern Visayas Regional Medical Center: Tacloban City, Philippines, 6500

This document is an instrument, sponge, and needle count sheet from the Eastern Visayas Regional Medical Center in Tacloban City, Philippines. It records information about a surgical procedure, including the patient's details, surgery type, start and end times, pre-operative and post-operative diagnoses, procedure performed, counts of instruments, sponges and needles used, and signatures of the medical staff involved.

Uploaded by

Marimiel Pagulayan
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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EASTERN VISAYAS REGIONAL MEDICAL CENTER

Tacloban City, Philippines, 6500


[email protected]

INSTRUMENT, SPONGE & NEEDLE COUNT SHEET

Date: _________________ Operating Room #: __________ Hospital No.: _____________


Name of Patient: _______________________________________ Age&Sex: ______________ Ward: ________________
Address: ______________________________________________ Date of Birth: ___________ Classification: _________

Surgeon: ___________________________________ Anesthesiologist: ____________________________


Assistant: __________________________________ Assistant: __________________________________
Assistant: __________________________________ Anesthesia Type: ______________ Surgery Type (Pls. Check)
Assistant: __________________________________ Time of Induction: _____________ Emergency
Time Started: _________ Elective
Time Ended: _________ Time Wheeled to OR: _________
Time Wheeled to PACU: _______

PRE-OPERATIVE DIAGNOSIS:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
POST-OPERATIVE DIAGNOSIS:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
OPERATION / PROCEDURE:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________

SPONGES INSTRUMENTS (MS #____)


Abdominal Packs: __________ Curve: ________________
Square Packs: _____________ Straight: ______________
OS 4x8: __________________ Allis: _________________ Scrub Nurse: ___________________________
OS 4x4: __________________ Babcock: _____________ Reliever: ______________________________
OS 2x2: __________________ Scalpel: ______________ Reliever: ______________________________
Cherries: _________________ Tissue Forcep: _________ Reliever: ______________________________
Pinkish: __________________ Thumb Forcep: ________
Peanuts: _________________ Debakey: _____________
Nasal Pack: _______________ Mayo Scissors: _________ Circulating Nurse: _______________________
Nasal Strips: ______________ Metzenbaum: _________ Reliever: ______________________________
Cottonoids: _______________ Needle Holder: _________ Reliever: ______________________________
Cotton balls: ______________ Towel Clips: ___________ Reliever: ______________________________
Epi. ball: _________________ Schnidts: _____________
Mixters: ______________
Traumatic Needles: Army Navy: ____________ Remarks: _____________________________
Round: _____ Cutting: _____ Richardson: ____________ _____________________________
STRANDS: _______________ _____________________
_____________________ _____________________
_____________________
Atraumatic Needles: _____________________ _______________________________
_________________________ _____________________ SIGNATURE OVER PRINTED NAME
_________________________ _____________________
_________________________ _____________________ ISNCS-OCN
_________________________ _____________________ Page 1 of 1
17-September-2018
_________________________
Rev. 00

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