NSGOR-FM-008/REV.

1/1JAN2021

MAYOR HILARION A. RAMIRO SR. MEDICAL CENTER

Maningcol, Ozamiz City

OPERATING ROOM REQUISITION SLIP (Medicines)

Shift: ________________________ Date: ______________

QNTY ITEMS AMOUNT QNTY ITEMS AMOUNT

Atropine SO4 amp.
Atracurium Besylate amp.
Bupivacaine Hcl 0.5 Heavy
Bupivacaine Hcl Isobaric
Butorphanol 2mg/ml amp.
Carboprost
Calcium Gluconate amp.
Dextran 500cc
Dopamine 250cc
D50 W 50ml
Epinephrine amp.
Ephedrine SO4 amp.
Fentanyl amp.
Heparin vial
Hydralazine HCL amp.
Hydrocortisone HCL
Isoflurane
Ketamine HCL
Ketorolac amp.
Metoclopramide HCL amp.
Mannitol 500cc
Magnesium Sulfate amp.
Midazolam amp.
Nalbuphine HCL amp.
Naloxone amp.
Nicardipine 2ml/amp.
Neostigmine amp.
Oxytocin 10 “u”/amp
Paracetamol 1 gram bot.
Paracetamol 300mg amp.
Pethidine HCL amp.
Plasmax
Propofol amp.
Promethazine amp.
Potassium HCL amp.
Rocuronium Bromide vial
Sevoflurane
Sodium Bicarbonate amp.
Succinylcholine
Suxamethonium Chloride

Requested by: _______________________________

Nurse on Duty ( Name & Signature)

Approved by: _______________________________

Nurse on Duty ( Name & Signature)