Capitol University

CU-QMS-NURSING-0014

College of Nursing
Cagayan de Oro City

OPERATING

ROOM CASES

Case Number:_______________

RECORD

Date of Operation:_________________

Name of Patient:_________________________________ Age:__________ Sex:_______

Civil Status:_______________ Ward/Room:_______________ Bed No.:_________
Name of Hospital:_______________________________________________________
Pre-Operative Diagnosis:

Operation Performed:

) Major Operation

) Minor Operation

) Circulating

Post-Operative Diagnosis:

Name of Surgeon:_________________________________
1st Asst:____________________________________
2nd Asst:____________________________________
Type of Anesthesia:________________________________
Anesthesiologist:___________________________________
Time Anesthesia Began:______________

Time Anesthesia Ended:____________

Time Operation Started:______________

Time Operation Ended:_____________

Name & Signature of Student:__________________________________

_____________________________

_____________________________

_____________________________

_____________________________

Name & Signature of OR Scrub Nurse

Name & Signature of OR Circulating Nurse

_____________________________

_____________________________

Name & Signature of OR Clinical Instructor

Name & Signature of OR Supervisor

Issue: 05April 2006

Revision Code :003

Capitol University

CU-QMS-NURSING-0015

College of Nursing
Cagayan de Oro City

DELIVERY

ROOM CASES

Case Number:_______________

RECORD

Date of Delivery:_________________
Time of Delivery:_________________

Name of Patient:_________________________________ Age:__________ Sex:_______

Civil Status:_______________ Ward/Room:_______________ Bed No.:_________
Name of Hospital:_______________________________________________________

Type of Delivery:__________________________________________
__________________________________________
Diagnosis:
GTPAL Scoring:____________________________
Name of Baby:_______________________________

Gender of Baby:_____________

Attending Physician:________________________________________
(

Handle

Assist

Cord Dressing

_____________________________

_____________________________

Name & Signature of Student

Name & Signature of DR Nurse-On-Duty

_____________________________

_____________________________

Name & Signature of DR Clinical Instructor

Name & Signature of DR Supervisor

Issue: 05April 2006

Revision Code :003