Peri-Operative Record Form Page 3

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PERI-OPERATIVE RECORD
AFFIX PATIENT INFO LABEL HERE
- Page 3 of 3 -
Patient Name_______________________ MR#_____________
POTENTIAL FOR INFECTION RELATED TO SURGICAL INTERVENTION
GOAL
Patient remains free of infection related to surgical intervention.
PLAN / IMPLEMENTATION
Maintain asepis of the surgical environment
SOLUTIONS
None
Betadine Scrub
Betadine Paint
Hibiclens
Technicare
Duraprep
Gelprep
Other __________________________________________________________________________________________
AREA SHAVED
None
Other _____________________________________ by __________________________________________________
PACKING
None
Type __________________________________________________________
Location __________________________________________
DRESSINGS
Xeroform
Steri-Strips
4 x 4s
Fluffs
ABD
Webril / Softroll
Ace Wrap
Post-Op Shoe
Sling
Cast / Splint ________________________________________________________________
Other __________________________________________________________________________________________________
POTENTIAL FOR FLUID IMBALANCE RELATED TO SURGICAL INTERVENTION
DRAINS
None
Type __________________________________________________________
Location __________________________________________
FOLEY CATHETER
None
Straight Catheter ____________ Fr.
Foley ____________ Fr.
___________ Balloon
Inserted by __________________ Color _________ Amount _________
Foley removed in OR:
No
Yes
BLOOD LOSS
EBL _______________________________________ Blood Products given:
No
Yes (see Anesthesia Record )
MEDICATION / IRRIGATION / SITE
TIME
INITIALS
IMPLANTS:
Include manufacturer, serial number, lot number, size & location.
Additional Implants listed on Progress Notes
COMMENTS: :__________________________________________________________________________________________________________________
:__________________________________________________________________________________________________________________
:__________________________________________________________________________________________________________________
Explain :_____________________________________
EVALUATION:
Aseptic technique is maintained to prevent infection?
Yes
No
:__________________________________________________________________________________________________________________
:__________________________________________________________________________________________________________________
DISCHARGE
PATIENT DISCHARGED TO
PACU
Phase II
Other _____________________________________________________________
TRANSPORT
Stretcher / side rails UP
Bed / side rails UP
Chair / Wheelchair
Ambulatory
O2 ___________ Liters
Other ___________________________________________________________________
All infusion Lines & Monitors Intact:
Yes
N/A
ACCOMPANIED TO PACU BY
MD
RN
Anesthesia Provider
Other _________________________________________________
STATUS
Awake
Alert
Drowsy
Agitated
Intubated
Other _________________________________________
REPORT GIVEN TO
__________________________________________
_____________________________________________________
____________________
, RN
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By
Time
Peri-Operative Record_OR
PAGE 3 of 3
S/N #821 Rev. 01/08

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