SAMPLE CHARTING (OR)

Date Special Endorsement Nurse’s Notes

Feb. 24, 2011 7-3

-received from DR with an IVF of
D5W 1L @ 800 cc level infusing well.
-with an indwelling foley catheter
attached to urine bag with an
output of 50 cc light colored urine
-pre-op consent checked
-transferred to OR table safely
-spinal prep done aseptically
9:50 am -induction of anesthesia by DR.
Nelson Gamboa
-skin prep done
-counting of instruments, needles
and sponges done
-proper draping done
10:07 am -LSCS by Dr. Reynaldo Alipio
assisted by Mrs. Elvira Morales
10:10 am -delivered an alive baby girl
10:12 am -delivered placenta
-above IVF changed to D5LRS +
20 “u” Sintocinon
-counting of instruments, sponges
and needles done/complete
-suturing layer by layer by
surgeon
-pressure dressing over incision
site
-IE done by Dr. Alipio
-to ward
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