NSG-FM-011/Rev.

2/1Jan2021

Republic of the Philippines

Department of Health
MAYOR HILARION A. RAMIRO SR. MEDICAL CENTER
Maningcol, Ozamiz City
INTRA-OPERATIVE NURSE’S RECORD

PATIENT’S NAME: AGE: SEX: WARD: HOSPITAL#: DATE:

NURSING DIAGNOSIS: NURSING GOALS & Interventions:

LEGEND:
□ Cautery Pad
∆ Pillows/Rolls
Straps
…….. Incision
+ Tourniquet
X Drains
© Cast
TRANSFERRED □Self
TIME IN:_______ □Assisted □Device___________________ per: □OR bed □Stretcher □Other_______

PRE-OP VITAL SIGNS: BP_______ HR_______RR______SPO2_______ Others: (GCS, Temp, Pain Scale)_____________
IV & BLOOD □N/A
COMPONENTS □YES IV line/Site/Level:________________________________________________________
______________________________________________________________________
□Blood Components/Site/Serial # and Blood Type:____________________________________
__________________________________________________________
POSITION □Supine □Prone □Lithotomy □Semi-Fowlers □Right Lateral □Left Lateral
□Jack Knife □Trendelenberg □Fracture Table Other:____________
SKIN CONDITION □Warm □Dry □Cold □Clammy □Other:________
WARMING DEVICE □Yes □N/A □Temp. Setting:______ Time On______ Time Off______
EQUIPMENT/’S USED □N/A □X-ray □C-arm
□Cardiac Machines:_________ □Suction Machine___________
□Optha Machines:__________ □Others:____________________
POSITIONING/ □Stirrups □Axillary Rolls □Heel Pads □Safety Strap □Chest Roll □Pillow □Gel Pad
PROTECTIVE AIDS □Armrest □Shoulder Roll □Arm Boards □Ioban □Doughout □N/A
ELECTROCAUTERY □N/A
□Yes □Harmonic □Monopolar □Bipolar
□Site:_____________________ Coag:_____________ Cut:_____________
Site Skin Condition After Removal:_________________________________
SKIN PREP □N/A □Yes Site:____________________________
□7.5% Betadine Cleanser □Sterilium
□70% Alcohol □Chlorhexidine
□10% Betadine Antiseptic □Others (Specify):____________
OB DELIVERIES □N/A □Assisted □NSVD □CS □Pfannenstiel □Midline □Classical □Others:
□Single A. Male Female Delivery Date & Time:_______________________
□Multifetal B. Male Female Delivery Date & Time:_______________________
C. Male Female Delivery Date & Time:_______________________
TOURNIQUET □N/A
□Yes Location:_____________________________ Tourniquet Used:____________
Time Inflated:________________________ Time Deflated:________________
IRRIGATION □N/A □PNSS □Irrigating Solution □Others:_________
DRAINS/CATHETERS □N/A □Yes Foley_____Fr. Inserted by:___________________ Time:_________
Return: □Clear □Yellow □Amber □Cloudy □Blood Tinged □Sediments
□Jackson Pratt □Hemovac □Penrose _____ in. □NGT____Fr. □Chest Tube Size: _______
N/A
□ YES : □Steri Strips □Retention Sutures □Stapler □Subcuticular □Others:_______
IMMOBILIZER/ □N/A
DRESSING □YES □Shoulders □Knee □Arm □Abd.Binder □Cervical Collar □Others:_______
Operation Ended: Time:____________
 NSG-FM-012/Rev.2/1Jan2021
CIRCULATING NURSE: ______________________________
Name & Signature
Republic of the Philippines
Department of Health
MAYORB HILARION A. RAMIRO SR. MEDICAL CENTER
Maningcol, Ozamiz City
NURSE’S POST-OPERATIVE HAND-OVER RECORD

AIRWAY STATUS □Intubated □Extubated □Oral Airway □Spontaneous Breathing

□Nasal Cannula/Face mask □Tracheostomy □Ambu Bagging
LEVEL OF CONSCIOUSNESS □Sedated but responsive to deep stimulus
□Sedated but responsive to verbal stimulus
□Awake and coherent
□Not responsive
IV/ BLOOD LINES SITE:
□PLR _____________ml _______________________
□D5LR____________ml _______________________
□PNSS ____________ml _______________________
□D5W ____________ml _______________________
□Blood/Blood Products
□FWB ________ml Bld Type_______ Serial #________________
□PRBC _______ml Bld Type_______ Serial #________________
□FFP ________ml
□ Platelet Conc. _____ml
□Side Drip/s: ___________
□Others: _______________
MEDICATION GIVE &
TIME GIVEN

URINARY CATHETERS □N/A

□Yes Output in OR:_______________ To discontinue in PACU
Return: □Clear □Yellow □Amber □Cloudy □Blood-tinged □Sediments:
POST-OP VITAL SIGNS BP:____ HR: ____ RR:___ SPO2: ___ Others: (GCS, tem[. Pain Scale) ___
TRANSFERRED □Self □Assisted □ Device used: _______________
TYPE OF TRANSPORT □Strecther □Wheelchair □Crib □Others:______________________
TRANSPORTED TO: □PACU □ICU □SICU □PICU □Ward/Room □Other_____ Time: _____
ACCOMPANIED BY: □Anesthesiologist □Surgeon □Nurse □ACN □Others:________
SPECIAL ENDORSEMENTS:

CIRCULATING NURSE: _________________________

Name & Signature