COLEGIO SAN AGUSTIN BACOLOD

COLLEGE OF HEALTH AND ALLIED PROFESSIONS

NURSING PROGRAM
B.S. Aquino Drive, Bacolod City
Contact Number: (034) 434 – 24 71 Local 162
Email Address: [email protected]

PRE-OPERATIVE CHECKLIST
Patient’s Name: Room & Bed No.: Sex: Age: Admission No.:
(Last Name) (First Name) (M.I.)

Attending Physician:

Name of Operation:

Note: The following item are necessary requirements and preparations to be done before patient’s scheduled
operation.
PRE-OPERATIVE ORDERS
1. Schedule approved and sent to OR
A. NPO Maintained
2. Consent for operation is done and signed B. Soap Suds Enema/Cleansing Enema done
Time: am ______
3. Legal representative have signed the consent pm ______
( ) Yes
( ) No C. Insert IVF done gtts/min_______
Time: am ______
4. Attending Anesthesiologist have signed and notified pm ______
Dr. ___________________________________________
5. Attending Surgeon have been notified PRE-OPERATIVE MEDICATIONS
Dr. ___________________________________________ ________________________________________________
6. Cardio-pulmonary clearance done by ________________________________________________
Dr. ___________________________________________ ________________________________________________
________________________________________________
7. Skin Preparation ________________________________________________
________________________________________________
8. Surgical Gown ________________________________________________
________________________________________________
9. Complete removal of the following item is done
a. Facial cosmetics Diagnostic Results attached
b. Jewelries
c. Dentures ____________ Blood reservations /cc
d. Nail Polish ____________ X-match
e. Hairpins ____________ CBC
f. Underwear ____________ Ultrasound
10. Patient made to void ____________ Others

______________________________________________ ________________________________________________
Date & Time Name & Signature of Staff Nurse on Duty
 COLEGIO SAN AGUSTIN BACOLOD
COLLEGE OF HEALTH AND ALLIED PROFESSIONS
NURSING PROGRAM
B.S. Aquino Drive, Bacolod City
Contact Number: (034) 434 – 24 71 Local 162
Email Address: [email protected]

INSTRUMENT AND SPONGE COUNT SHEET

Patient: ___________________________________________________ Room: ________ Date: ___________
Operation Performed: ______________________________________________________________________
________________________________________________________________________________________
Surgeon: ______________________________________ Anesthesia: ________________________________
Scrub Nurse: ___________________________________ Circulating Nurse: __________________________

Initial Surgical Surgical Floor Total

I. SPONGES Count Additional Field Table Count
AP Pack
Cherry Balls
OS Packs
4 x 4 sponge
Peanuts
Rolled Gauze
Square Pack

II. INSTRUMENT
Kelly Straight
Kelly Curve
Mayo Straight
Mayo Curve
Metz Curve
Tissue Forcep without Teeth
Tissue Forcep with Teeth
Blade Holder #3
Blad Holder #4
Allis Forcep
Babcock
Towel Clips
Army Navy
Richardson
Needle Holder
Suture needles
Free needles

III. ADDITIONAL INSTRUMENTS

Initial Instruments/Sponges counted by: _______________________________________________________________

Final Instruments/Sponges counted by: ________________________________________________________________
Remarks: _________________________________________________________________________________________
 COLEGIO SAN AGUSTIN BACOLOD
COLLEGE OF HEALTH AND ALLIED PROFESSIONS
NURSING PROGRAM
B.S. Aquino Drive, Bacolod City
Contact Number: (034) 434 – 24 71 Local 162
Email Address: [email protected]

OPERATING ROOM RECORD

Admission No.: _______________ Case No.: ____________ Room/Ward: ___________

Name: _____________________________ Age: _____ Sex: ______ Status: ______ Birthday: ___________

Address: _______________________________________________________________________________

( ) SSS ( ) GSIS ( ) Self-Employed ( ) Dependent ( ) OWWA ( ) Pensioner ( ) Indigent

Pre-Operative Diagnosis: ___________________________________________________________________

________________________________________________________________________________________
Post-Operative Diagnosis: __________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________

Operation Performed: ______________________________________________________________________

_________________________________________________________________ RVS Code: _____________
Operative Findings: ________________________________________________________________________
________________________________________________________________________________________

Date:______________ Operation Started: _________ Operation Ended: __________ Duration: ___________

Surgeon: ___________________________________ Assistants: ___________________________________
Anesthesiologist: _____________________________ Anesthesia: __________________________________
Anesthesia Started: ___________________________ (Please See Anesthesia Record)

Scrub Nurse: ________________________________ Circulating Nurse: _____________________________

Student Nurse / CI : _______________________________________________________________________

Initial Sponge & Instrument Counted by: _______________________________________________________

Final Sponge & Instrument Counted by: ________________________________________________________
Specimen___________________________ Laboratory _______________ Packing _____________________
Blood Transfusion: ________________________________________________________________________
Venoclysis: ______________________________________________________________________________

Medication during Operation

Time: __________ Medication and Dosage: _________________________________________________
Time: __________ Medication and Dosage: _________________________________________________

_________________________________ ___________________________________
Anesthesiologist Surgeon

Nurses Notes:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________

Initial BP: _____________ Urine Output: ____________ Nurse on Duty: ________________________________________

Name and Signature
 COLEGIO SAN AGUSTIN BACOLOD
COLLEGE OF HEALTH AND ALLIED PROFESSIONS
NURSING PROGRAM
B.S. Aquino Drive, Bacolod City
Contact Number: (034) 434 – 24 71 Local 162
Email Address: [email protected]

SURGICAL TIME OUT

Date : _____________________________________________________

Patient’s Name : _____________________________________________________

Age : _____________________________________________________

Operation to Perform : _____________________________________________________

Consent : _____________________________________________________

Surgeon : _____________________________________________________

Assistant Surgeon : _____________________________________________________

Anesthesiologist : _____________________________________________________

Anesthesia : _____________________________________________________

Scrub Nurse : _____________________________________________________

Circulating Nurse : _____________________________________________________

Pre-op Meds : _____________________________________________________

Allergies : _____________________________________________________

Blood Available : _____________________________________________________

Laboratory Results : _____________________________________________________

Special Orders : _____________________________________________________