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JAI KAMAL EYE HOSPITAL

(PASSIVE AUDIT)
DEPARTMENT: OPHTHALMOLOGY (SURGERY)

CATEGORIES UHID: UHID: UHID: UHID: UHID:


1. Admission consent and counselling
(Yes/No)
2. Consent for Eye Surgery (Yes/No)

3. Surgical Safety checklist

4. Anaesthesia Record:

a. PAC Form

b. Intra-operative Record Form

c. Anaesthesia Consent Form (Yes/No)

d. Informed Consent Form (Yes/No)

e. Post Anaesthesia Care Form

f. Operation Notes

g. Aseptic Dressing Chart (A/NA)

h. Pre-operative assessment & post-


operative care

5. Discharge summary

6. Operation notes

7. Covid-19 declaration form

8. Lab Reports, ECG


AUTHO SIGN:

MONTH:
JAI KAMAL EYE HOSPITAL
(PASSIVE AUDIT)
DEPARTMENT: OPHTHALMOLOGY (SURGERY)

CATEGORIES UHID: UHID: UHID: UHID: UHID:


1. Admission consent and counselling
(Yes/No)
2. Consent for Eye Surgery (Yes/No)

3. Surgical Safety checklist

4. Anaesthesia Record:

a. PAC Form

b. Intra-operative Record Form

c. Anaesthesia Consent Form (Yes/No)

d. Informed Consent Form (Yes/No)

e. Post Anaesthesia Care Form

f. Operation Notes

g. Aseptic Dressing Chart (A/NA)

h. Pre-operative assessment & post-


operative care

5. Discharge summary

6. Operation notes

7. Covid-19 declaration form

8. Lab Reports, ECG


AUTHO SIGN:

MONTH:

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