NURSING DEPARTMENT

NAME OF INSTITUTION: COTABATO PROVINCIAL HOSPITAL (CPH) Amas, Kidapawan City

OPERATING ROOM CASE SLIP: SCRUB NURSE (Major case)

Case No: ______________ Hosp. No: ______________ Date of Operation: _____________________________________

Time Started of operation: _______________ Time Completed: ______________________________________________
Name of Patient: ___________________________________ Age: _______________Sex: ___________________________
Address: ________________________________________________________________________________________________
Name of Operation: _____________________________________________________________________________________
_____________________________________________________________________________________
Pre-Operative Diagnosis: _________________________________________________________________________________
_________________________________________________________________________________
Post-Operative Diagnosis: _________________________________________________________________________________
_________________________________________________________________________________
Surgeon: ________________________________________ Asst. Surgeon________________________________________
Anesthesiologist: _________________________________ Type of Anesthesia: ___________________________________
Scrub Nurse 1 (Student):______________________________ Scrub Nurse 2 (Student):__________________________
Circulating Nurse 1(Student):__________________________Circulating Nurse 2 (Student):_____________________
Clinical Instructor: ____________________________________OR Nurse on Duty: _________________________________
(Signature over Printed Name) (Signature over Printed Name)

NURSING DEPARTMENT
NAME OF INSTITUTION: COTABATO PROVINCIAL HOSPITAL (CPH) Amas, Kidapawan City
OPERATING ROOM CASE SLIP: CIRCULATING NURSE (Major case)

Case No: ______________ Hosp. No: ______________ Date of Operation: _____________________________________

Time Started of operation: _______________ Time Completed: ______________________________________________
Name of Patient: ___________________________________ Age: _______________Sex: ___________________________
Address: ________________________________________________________________________________________________
Name of Operation: _____________________________________________________________________________________
_____________________________________________________________________________________
Pre-Operative Diagnosis:_________________________________________________________________________________
_________________________________________________________________________________
Post-Operative Diagnosis:_________________________________________________________________________________
_________________________________________________________________________________
Surgeon: ________________________________________ Asst. Surgeon________________________________________
Anesthesiologist: _________________________________ Type of Anesthesia: ___________________________________
Scrub Nurse 1 (Student):_________________________________ Scrub Nurse 2 (Student):__________________________
Circulating Nurse 1(Student):_____________________________Circulating Nurse 2 (Student):_____________________
Clinical Instructor: _____________________________________ OR Nurse on Duty: _________________________________
(Signature over Printed Name) (Signature over Printed