Peri-Operative Record Form Page 2
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1
2
3PERI-OPERATIVE RECORD
AFFIX PATIENT INFO LABEL HERE
- Page 2 of 3 -
Patient Name_______________________ MR#_____________
SCRUB NURSES
TITLE
IN
OUT
IN
OUT
CIRCULATING NURSES (Signature)
TITLE
IN
OUT
IN
OUT
POTENTIAL FOR ANXIETY RELATED TO KNOWLEDGE OF DEFICIT
GOAL
Patient demonstrates decreased anxiety.
PLAN / IMPLEMENTATION
Minimize noxious stimuli
Describe peri-operative events
Give clear, concise explanations
Remain with Patient during induction
:______________________________________________________________________________________________________
OTHER & COMMENTS
EVALUATION
Patient remains calm during induction and / or procedures:
Yes
No (explain) :_______________________________________________________________________________
:__________________________________________________________________________________________________________________
POTENTIAL FOR INJURY RELATED TO THE OPERATING ROOM ENVIRONMENT
GOAL
Patient is free from injury related to position, chemical, physical, thermal & electrical hazards: Patient's skin remains intact.
PLAN / IMPLEMENTATION
Positioned by: ________________________________________________________________________________
POSITION
Supine
Prone
Jackknife
Right Lateral
Left Lateral
Lithotomy
Semifowlers
Other: _____________________________________________________________________________________________________
°
ARMS SECURED
Right
Padded armboard / less than 90
Tucked at side
Other: ____________________________________________
°
Left
Padded armboard / less than 90
Tucked at side
Other: ____________________________________________
POSITIONING DEVICES
Safety strap over thighs
Donut under head
Foam support under head
Pillow under head
Axillary roll
Right:___ Left:___
Foam Pads: ______________________________________________
Pressure Areas
Stirrups
Toboggan
Chest Rolls
Kidney Braces
Hand Table
noted after positioning
Orthopedic positioning device: _____________________________________________________________________
____________________
Neurologic positioning device: _____________________________________________________________________
____________________
Comments: _________________________________________________________________________________________
CAUTERY
Monopolar #:_________
Bipolar #:___________
Grounding pad placement ______________ by ______________, RN
None
Other Cautery type: _____________________________________________ # _____________________________
TOURNIQUET
None
Yes Site :________________ Pressure______mmHg
Inflate Right ________
Deflate Right ___________
_________________________________
Applied By:
Inflate Left _________
Deflate Left ___________
BAIR HUGGER
None
Monitored by Anesthesia Heating Unit #____________
Temperature ________________________________
TED STOCKINGS
None
Thigh-high
Knee-high
Arrived with Stockings
SEQUENTIAL COMPRESSION
None
Thigh-high
Knee-high
Max Pressure 35-55 mmHg
Unit #___________
RADIOLOGY
None
X-Ray
Fluoroscopy
Shields for Patient / Staff
SPECIMENS
NO
YES
SITE
SPECIMENS
NO
YES
SITE
Pathology
Cytology
Microbiology
COUNTS
PRE - OP
CAVITY CLOSURE
SKIN CLOSURE / FINAL
correct
incorrect
not required
correct
incorrect
not required
correct
incorrect
not required
Instruments
Sponges
Sharps
RN Initials:
Time:
RN Initials:
Time:
RN Initials:
Time:
In incorrect count, action taken: _________________________________________________________________________________________________
Evaluation: Patient remains free from injury
Free from injury
Injury ____________________________________________________
Peri-Operative Record_OR
S/N #821 Rev. 01/08
PAGE 2 of 3
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