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Pre-Op
• • •
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Surgery Confirmed w/Patient
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Physical Limitations
• • •
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Items Removed from patient
• • •
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NPO?
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Post-Op DX
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To OR#:
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Transport Method
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Type of Anes
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In Room Time:
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Procedure Start Time:
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Procedure End Time
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Out of Room Time:
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Personnel
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Surgeon:
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Anesthesia:
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Tech:
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Other:
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Includes
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Patient Identification?
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Surgery Site/Side Marked
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Implants?
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Implant Lot Number:
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Procedure
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Antibiotics given?
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Consents Signed/Dated?
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Labs
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H&P
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Patient Position
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Skin Prep (Location)
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Skin Prep - Type
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ESU Sound Pad Placement
• • •
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Warmer
• • •
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Safety Belt
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Safety Belt Location
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EBL
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IV Intake
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Foley Output
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Time Out at
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By:
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Acknowledged By
• • •
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Other:
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All verbal orders given by a physician were read back for verification prior to administration or implementation.
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Intra-Operative Drugs
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Antibiotic Solution
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Bacitracin
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Ancef
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Gentamycin in 1000ml NaCl
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Tumescent Solution
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1:1000 Epinephrine
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lidocaine 1% Plain
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Local Medications
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Instruments Sterilized at
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Counts
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Rays (1st)
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Rays - Add
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Rays - Final
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RAYS - Drains
• • •
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LAPS - (1st)
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LAPS - Add
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LAPS - Final
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KB - (1st)
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KB - Add
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KB - Final
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Implant Labels
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BT - (1st)
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BT - Add
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BT - Final
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HP - (1st)
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HP - Add
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HP - Final
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Right
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Left:
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N (Suture)
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N (Suture) - Add
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N-Suture - Final
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Nurse Initial - (1st)
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Nurse Initial - Add
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Nurse Initial - Final
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Wound Class
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Lab Specimen(s)
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To PACU via:
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Patient Status
• • •
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Nurse Notes
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Nurse Signature
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Nurse Signature: Date/Time
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