DATE/TIME FOCUS PROGRESS NOTE (D-A-R)

09/10/18 Pre-operative Preparation DATA: Into OR per stretcher with ongoing IVF of
9:00 a.m. D5LR at 500cc level; infusing well
Consent to surgery signed and attached to
chart
Confirmed identity and procedure
Anesthesia Induction ACTION: Placed on OR table
Cardiac monitor attached
Initial V/S taken as follows:
BP: 120/90 mmhg
CR: 66 bpm
RR: 19 cpm
O₂ Sat: 97%
9:15 a.m.
Induction of spinal anesthesia done by Dr. Sabado

m
er as
Anesthesia Evaluation

co
Repositioned to supine with arms extended on
eH w
arm-board, arm-strap applied;
Electro-surgical pad placed under left thigh
o.
rs e

O₂ inhalation administered via nasal

ou urc

cannula
Catheterization done
Surgical prepping done
o

Draped aseptically
aC s

Initial counting of instruments: sharps,

vi y re

needles and sponges done

9:30 a.m. Operation Started

ed d

Open Reduction and Internal Fixation (ORIF) with

plates and screw fixed and done at the site by Dr.
ar stu

Villanueva.
Penrose drainage applied
Final counting done and verified
is

Left upper thigh closure completed

Th

2:20 p.m. End: OR Antiseptic solution and top dressing applied and
secured
sh

2:40 p.m. Unit Transfer Immediate post-operative care

Transferred to RR and endorsed

SUBMITTED TO:
MRS. JEBETH RELLOSO MAN, LPT PREPARED BY:
MARIA TERESA BAÑAGA
MELODY BARICAS
BSN lll

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