CIRCULATING NURSE (INITIAL / FINAL COUNTING) CIRCULATING NURSE (INITIAL / FINAL COUNTING)

Good afternoon! Dr. __________ (surgeon) and Dr. Good afternoon! Dr. __________ (surgeon) and Dr.
_________ (Anesthesiologist) and the rest of the surgical _________ (Anesthesiologist) and the rest of the surgical
team. team.

_________ (initial/Final) counting of all sponges, needles, _________ (initial/Final) counting of all sponges, needles,
sharps, and instruments are all counted and complete. sharps, and instruments are all counted and complete.
Thank you! Thank you!

CIRCULATING NURSE (INITIAL / FINAL COUNTING) CIRCULATING NURSE (INITIAL / FINAL COUNTING)

Good afternoon! Dr. __________ (surgeon) and Dr. Good afternoon! Dr. __________ (surgeon) and Dr.
_________ (Anesthesiologist) and the rest of the surgical _________ (Anesthesiologist) and the rest of the surgical
team. team.

_________ (initial/Final) counting of all sponges, needles, _________ (initial/Final) counting of all sponges, needles,
sharps, and instruments are all counted and complete. sharps, and instruments are all counted and complete.
Thank you! Thank you!

CIRCULATING NURSE (INITIAL / FINAL COUNTING) CIRCULATING NURSE (INITIAL / FINAL COUNTING)

Good afternoon! Dr. __________ (surgeon) and Dr. Good afternoon! Dr. __________ (surgeon) and Dr.
_________ (Anesthesiologist) and the rest of the surgical _________ (Anesthesiologist) and the rest of the surgical
team. team.

_________ (initial/Final) counting of all sponges, needles, _________ (initial/Final) counting of all sponges, needles,
sharps, and instruments are all counted and complete. sharps, and instruments are all counted and complete.
Thank you! Thank you!

CIRCULATING NURSE (INITIAL / FINAL COUNTING) CIRCULATING NURSE (INITIAL / FINAL COUNTING)

Good afternoon! Dr. __________ (surgeon) and Dr. Good afternoon! Dr. __________ (surgeon) and Dr.
_________ (Anesthesiologist) and the rest of the surgical _________ (Anesthesiologist) and the rest of the surgical
team. team.

_________ (initial/Final) counting of all sponges, needles, _________ (initial/Final) counting of all sponges, needles,
sharps, and instruments are all counted and complete. sharps, and instruments are all counted and complete.
Thank you! Thank you!

CIRCULATING NURSE (INITIAL / FINAL COUNTING) CIRCULATING NURSE (INITIAL / FINAL COUNTING)

Good afternoon! Dr. __________ (surgeon) and Dr. Good afternoon! Dr. __________ (surgeon) and Dr.
_________ (Anesthesiologist) and the rest of the surgical _________ (Anesthesiologist) and the rest of the surgical
team. team.

_________ (initial/Final) counting of all sponges, needles, _________ (initial/Final) counting of all sponges, needles,
sharps, and instruments are all counted and complete. sharps, and instruments are all counted and complete.
Thank you! Thank you!

CIRCULATING NURSE (INITIAL / FINAL COUNTING) CIRCULATING NURSE (INITIAL / FINAL COUNTING)

Good afternoon! Dr. __________ (surgeon) and Dr. Good afternoon! Dr. __________ (surgeon) and Dr.
_________ (Anesthesiologist) and the rest of the surgical _________ (Anesthesiologist) and the rest of the surgical
team. team.

_________ (initial/Final) counting of all sponges, needles, _________ (initial/Final) counting of all sponges, needles,
sharps, and instruments are all counted and complete. sharps, and instruments are all counted and complete.
Thank you! Thank you!
IMMEDIATE CARE OF THE NEWBORN (CORD CARE) OR CASES:
Date Performed: ________________ 1. Date Performed: ________________
Time started: ___________________ 2. Case number: ___________________
Pt initials: _______________________ 3. Pt name: _______________________
Case Number: __________________________ 4. Start: __________________________
CORD CARE PERORMED: DR, NURSERY, NICU, HOME 5. End: ___________________________
DR Nurse’s name: ANGELINE CLAIR N. RUBIA RN, MN 6. Surgical procedure:
Clinical Instructor: _________________________ ____________________________________________________
____________________________________________________
7. OR Nurse’s name: JORIESA L. MADRIDONDO RN, MN
IMMEDIATE CARE OF THE NEWBORN (CORD CARE)
Date Performed: ________________
OR CASES:
Time started: ___________________
PtDate Performed:
initials: ________________
_______________________
CaseNumber:
Case number:__________________________
___________________
Pt name:
CORD CARE_______________________
PERORMED: DR, NURSERY, NICU, HOME
DRStart: __________________________
Nurse’s name: ANGELINE CLAIR N. RUBIA RN, MN
End: ___________________________
Clinical Instructor: __________________________
: Surgical procedure:
_________________________________________________________
IMMEDIATE CARE OF THE NEWBORN (CORD CARE)
_______________________________________________
Date Performed: ________________
OR Nurse’s
started:name: JORIESA L. MADRIDONDO RN, MN
Time ___________________
Pt initials: _______________________
Case Number: __________________________ OR CASES:
CORD CARE PERORMED: DR, NURSERY, NICU, HOME Date Performed: ________________
DR Nurse’s name: ANGELINE CLAIR N. RUBIA RN, MN Case number: ___________________
Clinical Instructor: _________________________ Pt name: _______________________
Start: __________________________
IMMEDIATE CARE OF THE NEWBORN (CORD CARE) End: ___________________________
Date Performed: ________________ Surgical procedure:
Time started: ___________________ _________________________________________________________
Pt initials: _______________________ _______________________________________________
Case Number: __________________________ OR Nurse’s name: JORIESA L. MADRIDONDO RN, MN
CORD CARE PERORMED: DR, NURSERY, NICU, HOME
DR Nurse’s name: ANGELINE CLAIR N. RUBIA RN, MN
Clinical Instructor: __________________________ OR CASES:
: Date Performed: ________________
Case number: ___________________
IMMEDIATE CARE OF THE NEWBORN (CORD CARE)
Pt name: _______________________
Date Performed: ________________
Start: __________________________
Time started: ___________________
End: ___________________________
Pt initials: _______________________
Surgical procedure:
Case Number: __________________________
_________________________________________________________
CORD CARE PERORMED: DR, NURSERY, NICU, HOME
_______________________________________________
DR Nurse’s name: ANGELINE CLAIR N. RUBIA RN, MN
OR Nurse’s name: JORIESA L. MADRIDONDO RN, MN
Clinical Instructor: _________________________

IMMEDIATE CARE OF THE NEWBORN (CORD CARE)

Date Performed: ________________ OR CASES:
Time started: ___________________ Date Performed: ________________
Pt initials: _______________________ Case number: ___________________
Case Number: __________________________ Pt name: _______________________
CORD CARE PERORMED: DR, NURSERY, NICU, HOME Start: __________________________
DR Nurse’s name: ANGELINE CLAIR N. RUBIA RN, MN End: ___________________________
Clinical Instructor: __________________________ Surgical procedure:
: _________________________________________________________
_______________________________________________
IMMEDIATE CARE OF THE NEWBORN (CORD CARE)
OR Nurse’s name: JORIESA L. MADRIDONDO RN, MN
Date Performed: ________________
Time started: ___________________
Pt initials: _______________________ OR CASES:
Case Number: __________________________ Date Performed: ________________
CORD CARE PERORMED: DR, NURSERY, NICU, HOME Case number: ___________________
DR Nurse’s name: ANGELINE CLAIR N. RUBIA RN, MN Pt name: _______________________
Clinical Instructor: _________________________ Start: __________________________
End: ___________________________
Surgical procedure:
IMMEDIATE CARE OF THE NEWBORN (CORD CARE)
_________________________________________________________
Date Performed: ________________
_______________________________________________
Time started: ___________________
OR Nurse’s name: JORIESA L. MADRIDONDO RN, MN
Pt initials: _______________________
Case Number: __________________________
CORD CARE PERORMED: DR, NURSERY, NICU, HOME
DR Nurse’s name: ANGELINE CLAIR N. RUBIA RN, MN
Clinical Instructor: __________________________
:
CIRCULATING NURSE (TIME OUT):
Today is ________________!
Good afternoon Dr. ____________ (Surgeon) and Dr.__________
(Anesthesiologist) and the rest of the surgical team.
I am ___________ (Student nurse) from JRSMU Main campus, Dapitan
city, acting as a circulating nurse for this case.
Patient is ____________ (pt. name), ______ (age), _____ (sex) to
undergo ___________________(operation) to be performed by
Dr.________ (Surgeon).
*Cardiopulmonary clearance cleared by Dr.___________.
Pt. is medically cleared to undergo risk stratification.
Pre op medications were administered:
1._____________________
2._____________________
3._____________________
Informed consent signed by the patient on ___________(date)
Thank you!
CIRCULATING NURSE (TIME OUT):
Today is ________________!
Good afternoon Dr. ____________ (Surgeon) and Dr.__________
(Anesthesiologist) and the rest of the surgical team.
I am ___________ (Student nurse) from JRSMU Main campus dapitan
city, acting as a circulating nurse for this case.
Patient is ____________ (pt. name), ______ (age), _____ (sex) to
undergo ___________________(operation) to be performed by
Dr.________ (Surgeon).
*Cardiopulmonary clearance cleared by Dr.___________.
Pt. is medically cleared to undergo risk stratification.
Pre op medications were administered:
1._____________________
2._____________________
3._____________________
Informed consent signed by the patient on ___________(date)
Thank you!

1.Date of operation: ___________ 1.Date of operation: ___________

2.Surgeon: ____________ 2.Surgeon: ____________
3.Anesthesiologist: _________ 3.Anesthesiologist: _________
4.Pt name: _____________________ 4.Pt name: _____________________
5.Age: ____________ 5.Age: ____________
6.Sex: _____________ 6.Sex: _____________
7.Operation performed: ______________________________ 7.Operation performed: ______________________________
8.Cp cleared by: Dr. _______________ 8.Cp cleared by: Dr. _______________
(Only if applicable) (Only if applicable)
9. Pre op medications: 9 Pre op medications:
1.________________ 1.________________
2.________________ 2.________________
3.________________ 3.________________
4._________________ 4._________________
10. consent signed on: ________ 10. consent signed on: ________

CIRCULATING NURSE (TIME OUT): CIRCULATING NURSE (TIME OUT):

Today is ________________!
Good afternoon Dr. ____________ (Surgeon) and Dr.__________
(Anesthesiologist) and the rest of the surgical team.
I am ___________ (Student nurse) from JRSMU Main campus, Dapitan
city, acting as a circulating nurse for this case.
Patient is ____________ (pt. name), ______ (age), _____ (sex) to
undergo ___________________(operation) to be performed by
Dr.________ (Surgeon).
*Cardiopulmonary clearance cleared by Dr.___________.
Pt. is medically cleared to undergo risk stratification.
Pre op medications were administered:
1._____________________
2._____________________
3._____________________
Informed consent signed by the patient on ___________(date)
Thank you!
Today is ________________!
Good afternoon Dr. ____________ (Surgeon) and Dr.__________
(Anesthesiologist) and the rest of the surgical team.
I am ___________ (Student nurse) from JRSMU Main campus dapitan
city, acting as a circulating nurse for this case.
Patient is ____________ (pt. name), ______ (age), _____ (sex) to
undergo ___________________(operation) to be performed by
Dr.________ (Surgeon).
*Cardiopulmonary clearance cleared by Dr.___________.
Pt. is medically cleared to undergo risk stratification.
Pre op medications were administered:
1._____________________
2._____________________
3._____________________
Informed consent signed by the patient on ___________(date)
Thank you!

1.Date of operation: ___________ 1.Date of operation: ___________

2.Surgeon: ____________ 2.Surgeon: ____________
3.Anesthesiologist: _________ 3.Anesthesiologist: _________
4.Pt name: _____________________ 4.Pt name: _____________________
5.Age: ____________ 5.Age: ____________
6.Sex: _____________ 6.Sex: _____________
7.Operation performed: ______________________________ 7.Operation performed: ______________________________
8.Cp cleared by: Dr. _______________ 8.Cp cleared by: Dr. _______________
(Only if applicable) (Only if applicable)
9. Pre op medications: 9 Pre op medications:
1.________________ 1.________________
2.________________ 2.________________
3.________________ 3.________________
4._________________ 4._________________
10. consent signed on: ________ 10. consent signed on: ________
CIRCULATING NURSE (TIME OUT):
Today is ________________!
Good afternoon Dr. ____________ (Surgeon) and Dr.__________
(Anesthesiologist) and the rest of the surgical team.
I am ___________ (Student nurse) from JRSMU Main campus, Dapitan
city, acting as a circulating nurse for this case.
Patient is ____________ (pt. name), ______ (age), _____ (sex) to
undergo ___________________(operation) to be performed by
Dr.________ (Surgeon).
*Cardiopulmonary clearance cleared by Dr.___________.
Pt. is medically cleared to undergo risk stratification.
Pre op medications were administered:
1._____________________
2._____________________
3._____________________
Informed consent signed by the patient on ___________(date)
Thank you!
CIRCULATING NURSE (TIME OUT):
Today is ________________!
Good afternoon Dr. ____________ (Surgeon) and Dr.__________
(Anesthesiologist) and the rest of the surgical team.
I am ___________ (Student nurse) from JRSMU Main campus dapitan
city, acting as a circulating nurse for this case.
Patient is ____________ (pt. name), ______ (age), _____ (sex) to
undergo ___________________(operation) to be performed by
Dr.________ (Surgeon).
*Cardiopulmonary clearance cleared by Dr.___________.
Pt. is medically cleared to undergo risk stratification.
Pre op medications were administered:
1._____________________
2._____________________
3._____________________
Informed consent signed by the patient on ___________(date)
Thank you!

1.Date of operation: ___________ 1.Date of operation: ___________

2.Surgeon: ____________ 2.Surgeon: ____________
3.Anesthesiologist: _________ 3.Anesthesiologist: _________
4.Pt name: _____________________ 4.Pt name: _____________________
5.Age: ____________ 5.Age: ____________
6.Sex: _____________ 6.Sex: _____________
7.Operation performed: ______________________________ 7.Operation performed: ______________________________
8.Cp cleared by: Dr. _______________ 8.Cp cleared by: Dr. _______________
(Only if applicable) (Only if applicable)
9. Pre op medications: 9 Pre op medications:
1.________________ 1.________________
2.________________ 2.________________
3.________________ 3.________________
4._________________ 4._________________
10. consent signed on: ________ 10. consent signed on: ________

CIRCULATING NURSE (TIME OUT): CIRCULATING NURSE (TIME OUT):

Today is ________________!
Good afternoon Dr. ____________ (Surgeon) and Dr.__________
(Anesthesiologist) and the rest of the surgical team.
I am ___________ (Student nurse) from JRSMU Main campus, Dapitan
city, acting as a circulating nurse for this case.
Patient is ____________ (pt. name), ______ (age), _____ (sex) to
undergo ___________________(operation) to be performed by
Dr.________ (Surgeon).
*Cardiopulmonary clearance cleared by Dr.___________.
Pt. is medically cleared to undergo risk stratification.
Pre op medications were administered:
1._____________________
2._____________________
3._____________________
Informed consent signed by the patient on ___________(date)
Thank you!
Today is ________________!
Good afternoon Dr. ____________ (Surgeon) and Dr.__________
(Anesthesiologist) and the rest of the surgical team.
I am ___________ (Student nurse) from JRSMU Main campus dapitan
city, acting as a circulating nurse for this case.
Patient is ____________ (pt. name), ______ (age), _____ (sex) to
undergo ___________________(operation) to be performed by
Dr.________ (Surgeon).
*Cardiopulmonary clearance cleared by Dr.___________.
Pt. is medically cleared to undergo risk stratification.
Pre op medications were administered:
1._____________________
2._____________________
3._____________________
Informed consent signed by the patient on ___________(date)
Thank you!

1.Date of operation: ___________ 1.Date of operation: ___________

2.Surgeon: ____________ 2.Surgeon: ____________
3.Anesthesiologist: _________ 3.Anesthesiologist: _________
4.Pt name: _____________________ 4.Pt name: _____________________
5.Age: ____________ 5.Age: ____________
6.Sex: _____________ 6.Sex: _____________
7.Operation performed: ______________________________ 7.Operation performed: ______________________________
8.Cp cleared by: Dr. _______________ 8.Cp cleared by: Dr. _______________
(Only if applicable) (Only if applicable)
9. Pre op medications: 9 Pre op medications:
1.________________ 1.________________
2.________________ 2.________________
3.________________ 3.________________
4._________________ 4._________________
10. consent signed on: ________ 10. consent signed on: ________
 Major Set: (sample)
1. Allis- 4
2. Kelly curve – 9
3. Needle holder - 2
4. Ovum Forcep - 1
5. Army navy -2
6. Tissue forcep w/o teeth- 1
7. Tissue forcep with teeth- 1
8. Metzenbaum – 1
9. Mayo curve – 1
10. Mayo straight – 1
11. Knife - 1
12. Babcock – 2
13. Kelly straight -4
14. Towel clips – 5
15. Kidney basin – 2
16. Suction tubing – 1
17. Suction tip – 1
18. Cautery – 1
19. Richardson Retractor- 2
20. Bladder retractor - 1
21. OS or sponges – 10
22. Visceral pack – 2
23. Vicryl 1 -1
24. Vicryl 2-0 – 1
25. Vicryl 3-0 - 1
LIST of INSTRUMENTS:
1. ___________________________
2. ___________________________
3. ___________________________
4. ___________________________
5. ___________________________
6. ___________________________
7. ___________________________
8. ___________________________
9. ___________________________
10. ___________________________
11. ___________________________
12. ___________________________
13. ___________________________
14. ___________________________
15. ___________________________
16. ___________________________
17. ___________________________
18. ___________________________
19. ___________________________
20. ___________________________
21. ___________________________
22. ___________________________
23. ___________________________
24. ___________________________
25. ___________________________
26. ___________________________
27. ___________________________
28. ___________________________
29. ___________________________
30. ___________________________
31. ___________________________
LIST of INSTRUMENTS:
1. ___________________________
2. ___________________________
3. ___________________________
4. ___________________________
5. ___________________________
6. ___________________________
7. ___________________________
8. ___________________________
9. ___________________________
10. ___________________________
11. ___________________________
12. ___________________________
13. ___________________________
14. ___________________________
15. ___________________________
16. ___________________________
17. ___________________________
18. ___________________________
19. ___________________________
20. ___________________________
21. ___________________________
22. ___________________________
23. ___________________________
24. ___________________________
25. ___________________________
26. ___________________________
27. ___________________________
28. ___________________________
29. ___________________________
30. ___________________________
31. ___________________________
LIST of INSTRUMENTS:
1. ___________________________
2. ___________________________
3. ___________________________
4. ___________________________
5. ___________________________
6. ___________________________
7. ___________________________
8. ___________________________
9. ___________________________
10. ___________________________
11. ___________________________
12. ___________________________
13. ___________________________
14. ___________________________
15. ___________________________
16. ___________________________
17. ___________________________
18. ___________________________
19. ___________________________
20. ___________________________
21. ___________________________
22. ___________________________
23. ___________________________
24. ___________________________
25. ___________________________
26. ___________________________
27. ___________________________
28. ___________________________
29. ___________________________
30. ___________________________
31. ___________________________