Date and Time

Focus Pre-operative Preparation Anesthesia Induction Anesthesia Evaluation

Operation started

Data- Action- Response D>Into OR per _______________ accompanied by _______________ with ongoing IVF of ______at ____ cc level infusing well at ___ arm, consent for surgery signed and attached to chart, confirmed identity, site, procedure and consent A>Ushered to ___ OR ambulatory and positioned comfortably on ________, monitors attached; initial vital signs taken as follows: BP= _____mmHg CR=____bpm RR=____cpm SPO2=____% A>Repositioned to ________ with arms extended on arm boards, arm straps applied; anesthetic effect assessed by anesthesiologist (Dr. _____________); electro-surgical pad placed under buttocks; ________________ skin prep done by _____________; draped aseptically by Dr. ____________; initial sponge and instrument count done, Time-out completed A>(Specify what was done)

Specimen out

D>____________ out (please include description of specimen)

End of operation Unit Transfer

A>Final sponge , needles, and instrument count done and verified correct by ________________, sign out completed, wound closure by layers done by surgeon _____________ A>Skin closure completed by same surgeon, antiseptic solution and top dressing applied and secured A>Immediate post-op care done, arm straps and electrosurgical pad removed, kept warm with blankets, transferred to RR bed, ensured safety, brought to recovery room per RR bed with IVF of ____ at _____ cc level, last BP= _______, CR=________,RR=_______, SPO2=______, surgical checklist, OR tech and anesthesia record attached to chart, specimen labeled and given to watcher with ______________ request, endorsed to RR nurse.

Date and Time

Focus Pre-operative Preparation Anesthesia Induction Anesthesia Evaluation

Operation started

Data- Action- Response D>Into OR per _______________ accompanied by _______________ with ongoing IVF of ______at ____ cc level infusing well at ___ arm, consent for surgery signed and attached to chart, confirmed identity, site, procedure and consent A>Ushered to ___ OR ambulatory and positioned comfortably on ________, monitors attached; initial vital signs taken as follows: BP= _____mmHg CR=____bpm RR=____cpm SPO2=____% A>Repositioned to ________ with arms extended on arm boards, arm straps applied; anesthetic effect assessed by anesthesiologist (Dr. _____________); electro-surgical pad placed under buttocks; ________________ skin prep done by _____________; draped aseptically by Dr. ____________; initial sponge and instrument count done, Time-out completed A>(Specify what was done)

Specimen out

D>____________ out (please include description of specimen)

End of operation Unit Transfer

A>Final sponge , needles, and instrument count done and verified correct by ________________, sign out completed, wound closure by layers done by surgeon _____________ A>Skin closure completed by same surgeon, antiseptic solution and top dressing applied and secured A>Immediate post-op care done, arm straps and electrosurgical pad removed, kept warm with blankets, transferred to RR bed, ensured safety, brought to recovery room per RR bed with IVF of ____ at _____ cc level, last BP= _______, CR=________,RR=_______, SPO2=______, surgical checklist, OR tech and anesthesia record attached to chart, specimen labeled and given to watcher with ______________ request, endorsed to RR nurse.