Republic of the Philippines
PROVINCIAL Health Office
ILOCOS SUR PROVICIAL HOSPITAL-GABRIELA SILANG
Vigan City
OPERATING ROOM RECORD
Name: ___________P. K_______________ Age: _18_ Sex: _M_ Civil Status: _ Single____
Ward: _______107________ OPD No: _____________ Hospital No: ______2000350_____
Operating Diagnosis:
_______________________________Appendecitis_______________________________
___________________________________________________________________________
Surgeon: ___________Dra. Eli Tacad, MD_____ 1st Asst. ____________________________
Anesthesiologist: _____Dr. Roy Tacal, MD_____ 2nd Asst. ___________________________
Anesthetic: ______Lidocaine________________ Time Anesthesia Begun: ____8:45 AM___
Operating Date: ______01/05/2021___________ Time Anesthesia Ended: _______________
Operating Begun: _______8:51_______AM/PM Surgical Nurse: ___Dienizs Labini, RN__
Operating Ended: _______9:51______AM/PM Circulating Nurse: _Hanna La Madrid, RN
Title of Operation(s) Performed
______________________________Appendectomy________________________________
___________________________________________________________________________
Tissue to Lab { } Yes
{/ } No
Description of Procedure:
Findings:
______________________, MD
O.R. Medication Order Sponge Count Verified
________________________
Signature
Drains: _________________________
Kind & Number
________________________
Comments