OPERATING ROOM SCRUB CASE SLIPS:

University of the Cordilleras

University of the Cordilleras

COLLEGE OF NURSING

COLLEGE OF NURSING

Gov. Pack Road, 2600 Baguio City

Gov. Pack Road, 2600 Baguio City

=====================================
=========

=====================================
=========

OPERATING ROOM SCRUB CASE SLIP:

OPERATING ROOM SCRUB CASE SLIP:

Major ( ) Minor ( )

Major ( ) Minor ( )

Agency: _________________________________________________
( )

Hospital ( )

Community ( )

Agency: _________________________________________________

Medical Mission
( )

Hospital ( )

Community ( )

Medical Mission

Address: ________________________________________________

Address: ________________________________________________

Name of Patient _________________________________________

Name of Patient _________________________________________

Case Number ___________________ Age ______ Gender ______

Case Number ___________________ Age ______ Gender ______

Operation Performed _____________________________________

Operation Performed _____________________________________

____________________________________________________

____________________________________________________

____________________________________________________

____________________________________________________

Date of Operation ________________________________________

Date of Operation ________________________________________

Time started _____________ Time completed _______________

Time started _____________ Time completed _______________

Scrub Nurse 1___________________________________________

Scrub Nurse 1___________________________________________

Scrub Nurse 2___________________________________________

Scrub Nurse 2___________________________________________

Circulating Nurse ________________________________________

Circulating Nurse ________________________________________

Name of OR Nurse ________________________________________

Name of OR Nurse ________________________________________

_____________________________________________

_____________________________________________

OPERATING ROOM CASE SLIPS:

University of the Cordilleras

University of the Cordilleras

COLLEGE OF NURSING

COLLEGE OF NURSING

Gov. Pack Road, 2600 Baguio City

Gov. Pack Road, 2600 Baguio City

=====================================
=========

=====================================
=========

OPERATING ROOM CIRCULATING CASE SLIP:

OPERATING ROOM CIRCULATING CASE SLIP:

Major ( ) Minor ( )

Major ( ) Minor ( )

Agency: _________________________________________________
( )

Hospital ( )

Community ( )

Medical Mission

Agency: _________________________________________________
( )

Hospital ( )

Community ( )

Medical Mission

Address: ________________________________________________

Address: ________________________________________________

Name of Patient _________________________________________

Name of Patient _________________________________________

Case Number ___________________ Age ______ Gender ______

Case Number ___________________ Age ______ Gender ______

Operation Performed ______________________________________

Operation Performed _____________________________________

______________________________________________________

____________________________________________________

_____________________________________________________

____________________________________________________

Date of Operation _________________________________________

Date of Operation ________________________________________

Time started _____________ Time completed _______________

Time started _____________ Time completed _______________

Scrub Nurse 1___________________________________________

Scrub Nurse 1___________________________________________

Scrub Nurse 2___________________________________________

Scrub Nurse 2___________________________________________

Circulating Nurse ________________________________________

Circulating Nurse ________________________________________

Name of OR Nurse ________________________________________

Name of OR Nurse ________________________________________

_____________________________________________

_____________________________________________

DELIVERY CASE SLIPS:

University of the Cordilleras

University of the Cordilleras

COLLEGE OF NURSING

COLLEGE OF NURSING

Gov. Pack Road, 2600 Baguio City

Gov. Pack Road, 2600 Baguio City

======================================
========
DELIVERY CASE SLIP: Actual ( )

Assist ( )

Agency: ____________________________________________
University of the Cordilleras
in ( )

======================================
========

Hospital ( OF
) NURSING
Home ( )
COLLEGE

DELIVERY CASE SLIP: Actual ( )

Agency: ____________________________________________
University of the Cordilleras

Birthing/ Lying-

Gov. Pack Road, 2600 Baguio City

Address: ____________________________________________
======================================
Name of Mother ________________________________________
========
Case Number
___________________
Age
____________________
IMMEDIATE
NEWBORN
CARE
CASE SLIP
Type
of Delivery
Attended _________________________________
Agency:
____________________________________________
____________________________________________________
Hospital ( )
Home ( ) Birthing/ Lying-in ( )
____________________________________________________
Address:
____________________________________________
Date of Delivery _________________________________________

Assist ( )

in ( )

Hospital
( )
Home ( )
COLLEGE
OF NURSING

Birthing/ Lying-

Gov. Pack Road, 2600 Baguio City

Address: ____________________________________________
======================================
Name of Mother ________________________________________
========
Case Number
___________________
Age CASE
____________________
IMMEDIATE
NEWBORN CARE
SLIP
Type____________________________________________
of Delivery Attended _________________________________
Agency:
____________________________________________________
Hospital ( )
Home ( ) Birthing/ Lying-in ( )
____________________________________________________
Address: ____________________________________________
Date of Delivery _________________________________________

Time
Time Placenta Out __________
NameofofDelivery
Mother _____________
________________________________________

of Delivery
_____________ Time Placenta Out __________
NameTime
of Mother
________________________________________

Actual
Nurse
___________________________________________
Name of
Baby
__________________________________________

Nurse
___________________________________________
NameActual
of Baby
__________________________________________

Assist
Nurse
___________________________________________
Date of
Delivery_________________
Time ___________________

Nurse ___________________________________________
Date Assist
of Delivery_________________
Time ___________________

Name
of DR Nurse/
Midwife _______________________________
Case Number
___________________
Gender _________________

of DR
Nurse/ Midwife Gender
_______________________________
Case Name
Number
___________________
_________________

Immediate Newborn Care Performed at:

Immediate Newborn Care Performed at:

_________________________________
Delivery
Room
(
)
Clinical
Instructors full Name
and
signature
Home
(
)
Nursery

Others _____________________________________

_________________________________
Delivery
Room
(
)
Clinical Instructors full
and signature
Home
( Name
)
Nursery

Others _____________________________________

Name of Performing Nurse ___________________________________

Name of Performing Nurse ___________________________________

Name of DR/ Nursery Nurse /Midwife: _________________________

Name of DR/ Nursery Nurse /Midwife: _________________________

__________________________________________

__________________________________________

Clinical Instructors full Name and signature

Clinical Instructors full Name and signature

IMMEDIATE NEWBORN
CARE CASE SLIPS: