CIRCULATION CASE ( Major / Minor )

Name of Patient: Sex: Civil

Status:

Address:

Date and Time of Admission:

Case/Hospital No:

Status Of Patient (Level of Consciousness):

Preoperative V/S: T= PR = RR=

BP:

IVFs (include level and # of lines, specify if any):

Blood Products (specify level, serial number, number of bags used):

Proposed Operation:

Preoperative meds given (Complete data):

Check box, then fill out required data (if applicable)

Removed: Nail Polish Dentures Jewelries

Informed Consent, updated/valid? Yes No Pls. report

to Staff Nurse ASAP

Foley Bag Catheter: Amount of Urine and Drainage:

Nasogastric Tube: Color and Amount of Drainage:

NPO Status: Specify actual number of hours:

 Chest Tube: Color and Amount of Drainage:

Colostomy Bag: Color and Amount of Drainage:

JP Drain: Color and Amount of Drainage:

Time of Transport to OR Theater: Time of Transfer to OR

Table:

Circulating Staff Nurse(s):

Circulating Student Nurse:

Scrub Student Nurse:

Anesthesiologist: Surgeon:

Type of Anesthesia:

Induction Time: Time of Anesthesia:

Anesthetics Given (include amount, specify site if spinal/epidural)

Instrument/ Set Used: (Specify, include quantity)

Additional (Not part of set):

Paraphernalia/Supplies Added (include quantity):

Sutures (Specify name and quantity):

Free ties (specify):

Time Specimen taken out/ Baby Out:

Accounting Time Remarks

1st count

2nd count

3rd count

4th count

Narrative Charting (do a brief, concise and complete nursing narration of

intervention)
Estimated Blood Loss: Amount of IVF’s used as
washing:

Operation(s) Performed:

Time Ended: Status of Patient Post-op (Level of

Consciousness):

Postoperative V/S: T= PR= RR= BP=

Postoperative Diagnosis:

Check (/) box then fill out required data (if applicable):

Foley Bag Catheter: Amount of Urine and Drainage:

Nasogastric Tube: Color and Amount of Drainage:

NPO Status: Specify actual number of hours:

 Chest Tube: Color and Amount of Drainage:

Colostomy Bag: Color and Amount of Drainage:

JP Drain: Color and Amount of Drainage:

IVF’s endorsed (specify level and no. of lines/site if applicable):

Blood Products (specify level, serial nos. and no. of bags used):

Doctor’s Order (Postoperatively)

Time of Transfer to Recovery Room/ Post-Anesthesia Care Unit:

Recovery Room Staff Nurse on Duty:

Recovery Room Student Nurse assigned to Patient:

Circulating SN Name/Signature Clinical Instructor

Name/Signature