SIGN IN

(Before Induction of Anesthesia)

Good  OR team. Our patient is Mr./Mrs.  from ,  years old who will
undergo . Consent signed and secured at ward seen and noted, hooked to pulse oximeter and
non-invasive Blood monitoring and Functioning well with initial Vital Signs of BP: , PR: , SaO2:
 with/without Allergies in drugs/foods.

Dr.  are there aspirations risks or airway difficulty to be addressed?

(Anesthesiologists)

Dr.  is there more than 500 ml of blood loss?

(Surgeon)

I’m Mr./Mrs.  from L-NU College of Nursing SIGNING IN.

TIME OUT

(Before Skin Incision)

To all Operating Room Team member please introduce yourself by name and role.

Dr.  what are the critical steps, operative duration, and anticipated blood loss?

(Surgeon)

Dr.  is there any patient specific concerns?

(Anesthesiologists)

Mr./Mrs.  has sterility been confirmed? Is there any equipment or issue need to be addressed?

(Circulating Nurse)

Mr./Mrs.  is there Prophylaxis Antibiotics given?

(Staff Nurse)

SIGN OUT

(Before the Patient leave the OR room)

Dr.  what is the procedure done to your patient?

(Surgeon)

Once again, our patient Mr./Mrs.  from ,  years old who underwent , I
would like to inform you that all sponges, instrument, and needles are counted correctly and complete.

Dr.  how would you put the specimen bottle and labeled?

(Surgeon)

Mr./Mrs.  is there any equipment or issues to be addressed?

(Circulating Nurse)

Dr.  what are the key concerns for the recovery and management of the patient?

(Surgeon)

Dr.  what are the key concerns for the recovery and management of the patient?

(Anesthesiologists)

I’m  from L-NU College of Nursing SIGNING OUT.