OR CHECKLIST OF REQUIREMENTS

S.Y.2023-2024

NAME: _____________________________________________________YR. LEVEL& SEC: ____________RLE GROUP:_________ DATE:____________

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 TOTAL NO. OF LATES ABSENCES

ITEMS DEFICIENCY
CAP AND MASK
SCRUB SUIT & GOWN
WATCH + NAME PLATE
INSIDE SLIPPERS
CHN UNIFORM
PPE
KN95 MASK (WHITE)
ORD. + STERILE GLOVES
DUTY BAG + PENLIGHT
BANDAGE SCISSORS
V/S EQUIPMENT
NAME STAMP
RLE COLUMNAR
RLE CALENDAR
SCRUB FORMS
HAIR AND NAILS
PRAYER GUIDE
CHARTING GUIDE
TIME-OUT GUIDE
REPERTING GUIDE
PENS WITH NAME
JOTDOWN NOTEBOOK
88mmx125(3.5x4.9)
ALCOHOL IN SMALL
SPRAYER
CUTASEPT 50ML/GROUP
FILE ORGANIZER
(PLEASE STATE THE FOLLOWING THAT APPLIES)

1. PRE-OPERATIVE ANTIBIOTICS GIVEN DURING THE PREVIOUS 60 MINUTES.

2. PRE-OPERATIVE MEDICATION GIVEN

3. SKIN TEST OF __________ DUE ON __________ AT THE __________

4. PRESENT IVF WITH _________ INCORPORATION

5. WITH AVAILABLE _____ UNIT/S OF ____ BLOOD. BLOOD TYPE ___. COMPATIBLE.

6. FOR CBG AT _________.

7. WITH INSULIN DRIP.

8. WITH X-RAY PLATE PLACED UNDER OPERATIVE SITE

9. REQUEST FOR INTRA-OPERATIVE X-RAY SENT

10. X-RAY FILM/S AVAILABLE

11. PORTABLE X-RAY WITH PLATE/S READY

12. NITRO PATCH PLACED OVER ACW

13. (FOR PEDIA) WEIGHT:_______KGS; TEMP:_____*C

THANK YOU! (YOU MAY PROCEED)

*DURING DRAPING*

(LET’S TAKE OUR TIME OUT!)

OPTION 1:

MEMBERS OF THE SURGICAL TEAM PLEASE INTRODUCE YOURSELVES AND ROLE.

OPTION 2:

LET US CONFIRM MEMBERS OF THE SURGICAL TEAM.

________, ________, ________, ________, ________, AND (FOR CS) ________.

(DOES EVERYONE AGREE WITH THAT) THIS IS

(WE HAVE HERE THE CASE OF) ________, ____ FROM _____ WITH AN IMPRESSION OF ________,

TO UNDERGO _______ IN _______ UNDER ________ VIA ________ WITH ________ BLOOD LOSS EXPECTED.
PRAYER BEFORE SURGERY

IN THE NAME OF THE FATHER…

DEAR LORD,

WE OFFER YOU ALL OUR UNDERTAKINGS AS WE ARE ABOUT TO BEGIN THE WORK ENTRUSTED TO US. GUIDE DR. ___________ AND DR.
___________. BLESS THEM WITH A STEADY AND SKILLFUL HANDS

TOGETHER WITH DR. ___________, WISDOM TO KNOW WHAT IS BEST TO BE DONE. BLESS ALSO

___________, ___________, AND ___________ TO BE SENSITIVE TO RESPOND TO THEIR NEEDS AND MOST

OF ALL BLESS ___________ WHO THROUGH YOU ENTRUSTED TO US HER/HIS PRECIOUS LIFE. GRANT THAT

WHAT WE ASK IS IN CONFORMITY WITH YOUR MOST HOLY WILL AMEN.

GLORY BE TO THE FATHER…

O MARY CONCEIVED WITHOUT SIN…

ST. ANTHONY… PRAY FOR US

IN THE NAME OF THE FATHER…