Peri-Operative Record Form

ADVERTISEMENT

PERI-OPERATIVE RECORD
AFFIX PATIENT INFO LABEL HERE
- Page 1 of 3 -
Patient Name_______________________ MR#_____________
Date:
Patient
Anesthesia
Time Out:
Procedure
in Room:
Start:
Start:
Suite #:
Patient out
Anesthesia
Procedure
of Room:
Finish:
Finish:
Patient Identification:
Verbal
ID Band
Verification of Operative Consent by Circulating RN
Pre-Op Assessment reviewed by Circulating RN
Pre-Op Checklist completed by Circulating RN
TIME Antibiotic
H & P reviewed by Circulating RN
Pre-Op Antibiotic:
Circulating RN
Time:
Started:
Signature:
Completed:
Antibiotic Name
WOUND CLASS
1 (clean)
2 (clean / contaminated)
3 (contaminated)
4 (infected)
ANESTHESIA
General
Spinal
MAC
Local / Block
Conscious Sedation
BP & Pulse monitored by ______________, RN
O2 Saturation & EKG monitored by ______________, RN
LEVEL OF CONSCIOUSNESS
Alert
Oriented
Disoriented
Drowsy / Sedated
Unconscious
Other: ________________________________________________________________________________________
EMOTIONAL STATUS
Calm
Cooperative
Nervous
Agitated
Crying
PHYSICAL / SENSORY DISABILITIES
None
Other:____________________________________________________
ALLERGIES
None
Other (specify) :___________________________________________________________________
NPO AFTER MIDNIGHT
Yes
No (specify) :_____________________________________________________________________
Fluids: ________________________________________________
Solids: _______________________________________________
SKIN CONDITION
Intact where seen
Warm
Cool
Dry
Diaphoretic
Pale
Pink
Flushed
Other:___________________________________________________________________
PROSTHETIC DEVICES
None
Other (specify) :___________________________________________________________________
DISEASE HISTORY
None
Other (specify) :___________________________________________________________________
:__________________________________________________________________________________________________________________
:__________________________________________________________________________________________________
PRE-OPERATIVE DIAGNOSIS:
:__________________________________________________________________________________________________________________
:__________________________________________________________________________________________________________________
:__________________________________________________________________________________________________
OPERATIVE PROCEDURES:
:__________________________________________________________________________________________________________________
:__________________________________________________________________________________________________________________
:__________________________________________________________________________________________________________________
:__________________________________________________________________________________________________________________
POST-OPERATIVE DIAGNOSIS: :__________________________________________________________________________________________________
:__________________________________________________________________________________________________________________
:__________________________________________________________________________________________________________________
Surgeon:
Surgeon:
Anesthesia Provider:
Assistant:
Other Personnel:
Other Personnel:
Peri-Operative Record_OR
PAGE 1 of 3
S/N #821 Rev. 01/08

ADVERTISEMENT

00 votes

Related Articles

Top 20 Happy Easter Cards And Gift Tags To Download For Free
Top Ten Easter Arts And Crafts Activities For Your Kids
Free Easter Coloring Pages And Easter Printables For Your Kids

Related forms

Form 7530 - Parking Lot And Garage Operations Tax Form - Department Of Revenue - Illinois Form 7530 - Parking Lot And Garage Operations Tax Form - Department Of Revenue - Illinois Financial
Form 7530 - Parking Lot And Garage Operations Tax Form - Chicago Department Of Revenue - Illinois Form 7530 - Parking Lot And Garage Operations Tax Form - Chicago Department Of Revenue - Illinois Financial
Form Fint122 - Texas Title Insurance Agent/direct Operation Bond Form - Texas Department Of Insurance Form Fint122 - Texas Title Insurance Agent/direct Operation Bond Form - Texas Department Of Insurance Legal
Form Fint130 - Application For Direct Operation License Form - Texas Department Of Insurance Form Fint130 - Application For Direct Operation License Form - Texas Department Of Insurance Legal
Form Mt-10 - Purchaser-operator Registration Form Form Mt-10 - Purchaser-operator Registration Form Financial
Form Pto-1595 (rev. 03-11) - Recordation Form Cover Sheet Form Pto-1595 (rev. 03-11) - Recordation Form Cover Sheet Legal
Recording Form For Oral Reading Recording Form For Oral Reading Education
Form Ssa-97-sm (04-11) - Employer Questionnaire - Discrepancy Between Irs And Ssa Records Form Form Ssa-97-sm (04-11) - Employer Questionnaire - Discrepancy Between Irs And Ssa Records Form Legal
Form Fda 1609a - Research Progress Record Form Form Fda 1609a - Research Progress Record Form Business
Form Lic 622 - Centrally Stored Medication And Destruction Record Form Form Lic 622 - Centrally Stored Medication And Destruction Record Form Legal

Related Categories

Parent category: Medical
Download
Go
Page of 3