SURGICAL COUNT INSTRUMENT, NEEDLES & SPONGES

Nama :________________________________________________________
Med. Rec. No :______________________ Usia :___________________
Jenis Kelamin :P/L Tanggal :___________________
Pre Operation Diagnosis :_________________________________________________
Operation Done :_________________________________________________
Post Operation Diagnosis :_________________________________________________
Surgeon :_____________________ Asist. Surgeon :___________________
Anesthesiologist :_____________________ Anesthesia Nurse:__________________
Scrub Nurse :_____________________ Circulating Nurse :__________________

Ovum Forceps Kidney Basin

Vulselum Bowl
Hegar’s Dilators Gauze 10x10
Double Speculum Prep. Balls
Double Ended Curettes
Big Curette
Uterine Sound

Instrument Used : D & C Set

Scrub Nurse :________________ Circulating Nurse :_____________

SURGICAL COUNT INSTRUMENT, NEEDLES & SPONGES

 Nama :________________________________________________________
Med. Rec. No :______________________ Usia :___________________
Jenis Kelamin :P/L Tanggal :___________________
Pre Operation Diagnosis :_________________________________________________
Operation Done :_________________________________________________
Post Operation Diagnosis :_________________________________________________
Surgeon :_____________________ Asist. Surgeon :___________________
Anesthesiologist :_____________________ Anesthesia Nurse:__________________
Scrub Nurse :_____________________ Circulating Nurse :__________________

Ovum Forceps Tooth Forceps

Allis Forceps Non tooth Forceps

Babcock Kidney Basin

Right angle Gallipots
Straight Kockers Towel Clip
Straight Artery Forceps Langenback retractor
Curved Artery Forceps Morris Retractor
Straight Mosquito Forceps Deaver
Curved Mosquito Sinn Retractor
Bowel Forceps Gauze 10x10
Metal Suction Pedia Pack 20x20
Big Blade Holder Abdominal Pack 40x40
Small Blade Holder Peanut

Needle Holder Cherries

Tissue Scissor Needles
Suture Scissor Prep. Balls

Instrument Used : ________________________________________________

Scrub Nurse :________________ Circulating Nurse :_____________