Case No.

:
Name of Student:
Year and Section

OR Preference Cards Circulating Nurse

Name of Patient:
Date of Admission:
Bed #:

Age:
Date of Surgery:
Hospital No:

Surgeon:
Scrub Nurse:

Sex:

Civil Status:
Time Started / Ended:

Assistant Surgeon:
Circulating Nurse:

Anesthesiologist:

Chief Complaint:
Patho-physiology:
Rationale / Definition:
Post Operative Diagnosis:
Rationale / Definition:
Complete Surgical Procedure:
Definition:
Indication:
General type of Anesthesia:
Specific Technique:
Skin Preparation/ Assistance Done:
Items Used to Administer Anesthesia:
Main Anesthetic Agent
Mechanism of Action:
Other Medications Used:
Mechanism of Actions
Position:
Equipments Used for Positioning
Incision:
Skin Preparation:
Disinfectant Used:
Draping:
Surgical Safety Checklist: Note Things noted and Observed

Sign In

Sample Charting:

Time Out

Sign Out