OR SAMPLE CHARTING OR SAMPLE CHARTING

EXCISION,  SUBAREOLAR BREAST MASS CAESAREAN SECTION

TIME > Into OR a __ year old __________ per wheelchair/stretcher
TIME > Into OR a __ year old female per wheelchair/stretcher accompanied by NOD & orderly with ongoing IVF of __________ @
accompanied by NOD & orderly with ongoing IVF of __________ @ __________cc level infusing well at _____ arm.
__________cc level infusing well at left arm. >Conscious & coherent
>Conscious & coherent >With consent signed for C.S.
>Informed Consent signed for Breast Mass Excision >Ushered to OR table in supine position
>Assisted to OR table in supine position > Cardiac Monitor attached w/ preop V/S
>Cardiac Monitor attached w/ preop V/S BP=_____________mmHg PR=_____________BPM
BP=_____________mmHg PR=_____________BPM RR=_____________CPM SPO2=___________%
RR=_____________CPM SPO2=___________% > O2 inhalation administered @ 2 LPM per nasal cannula
>O2 inhalation administered @ 2 LPM per nasal cannula >Repositioned to side lying with knees flexed
> Breast skin prepared done by NOD. >Lumbar skin prepped done by NOD.
>Draped aseptically >Draped aseptically
TIME >Local Anesthesia infiltrated over breast mass TIME >Operation started wherein a midline incision was done by
TIME >Operation started by Dr. _________________ wherein small Dr. _________________ assisted by Dr. _________________
incision was done >Incision deepened to peritoneum
>Incision deepened >Amniotic sac artificially ruptured and fluid suctioned
TIME >Specimen out >Uterus incised
>Drain placed >Fetal head was delivered
>Suturing of incision done by Dr. _________________ TIME >Delivered an alive baby _______ in cephalic presentation via C.S.
TIME >Operation finished >Double clamping of umbilical cord then cut
>Reapplication of betadine swab on sutured incision and secured w/ >Immediate NB care rendered by Pediatrician Dr. _____________
top dressing TIME >Placenta out complete in Schultz presentation followed with
>Post op care done thorough evacuation of uterine blood clots.
>Post op V/S of BP= __________mmHg, PR= __________BPM, RR= >Uterine incision sutured by layer
__________CPM, SPO2=___________% >Bilateral Tubal Ligation done
TIME >Into recovery room per stretcher with same IVF of __________ @ TIME >Left fallopian out
__________cc level. TIME >Right fallopian out
>Final count of sponges, needles and instruments complete in the
Sarah presence of the NOD
>Abdominal incision sutured layer by layer done by surgical team
TIME >Operation finished
TIME >Above IVF consumed and changed with same _______ + _______ >Hemostasis ensured
“u” oxytocin >Incision sutured layer by layer done by surgical team
>Reapplication of betadine swab on sutured incision; sutured with TIME >Operation finished
top dressing. >Reapplication of betadine swab on sutured incision and secured w/
>Manual evacuation of blood clots top dressing
>Post-op care done >Post op care done
> Post op V/S of BP= __________mmHg, PR= __________BPM, RR= >Post op V/S of BP= __________mmHg, PR= __________BPM, RR=
__________CPM, SPO2=___________% __________CPM, SPO2=___________%
>Urine output of ____cc TIME >Into recovery room per stretcher with same IVF of __________ @
TIME >To recovery room per stretcher with same ongoing IVF of _______ __________cc level.
+ _______ “u” oxytocin @ _______cc level. Sarah
Sarah Exploratory Laparotomy
TIME > Into OR a __ year old female per wheelchair/stretcher
OR CHARTING accompanied by NOD & orderly with ongoing IVF of __________ @
TIME > Into OR a __ year old female per wheelchair/stretcher __________cc level infusing well at left arm.
accompanied by NOD & orderly with ongoing IVF of __________ @ >Facial grimace noted
__________cc level infusing well at left arm. >Moans when in pain
>Conscious & coherent >With NGT connected to drainage bottle
>Informed Consent signed for ___________________ >With intact IFC
>Ushered to OR table in supine position >Pale in appearance
> Cardiac Monitor attached w/ preop V/S >Informed Consent signed for Exploratory Laparotomy
BP=_____________mmHg PR=_____________BPM >Ushered to OR table in supine position
RR=_____________CPM SPO2=___________% > Cardiac Monitor attached w/ preop V/S
> O2 inhalation administered @ 2 LPM per nasal cannula BP=_____________mmHg PR=_____________BPM
>Repositioned to side lying with knees flexed RR=_____________CPM SPO2=___________%
>Lumbar skin prepped done by NOD TIME >PNSS 1L hooked at _____ arm
TIME >Spinal Anesthesia induced by Dr. _________________ TIME >General Anesthesia inducted by Dr. _________________
>Back to supine position TIME >Intubation done noted
>Abdominal skin prepped done by NOD >Abdominal skin prepped done by NOD
>Draped aseptically >Draped aseptically
TIME > Operation started wherein a _____________ incision was done by >Draped aseptically
Dr. _________________ assisted by Dr. _________________ TIME > Operation started wherein a midline vertical incision was done by
>Incision deepened to peritoneum Dr. _________________ assisted by Dr. _________________
>Identification and isolation of diseased organ >Incision deepened until peritoneum
TIME >Specimen out
TIME >Above IVF of ___________ discontinued and changed to packed
RBC at ____arm
>Evacuation of hemoperitoneum
>Exploration and inspection of intra-abdominal cavity
>Liver packing done at site of liver injury with subsequent
application of gel foam
>Hemostasis ensured
TIME >Above IVF on the _____arm consumed and changed to
____________
>Abdominal incision sutured layer by layer done by surgical team
TIME >Operation finished
>Reapplication of betadine swab on sutured incision and secured w/
top dressing
>Post op care done
>Post op V/S of BP= __________mmHg, PR= __________BPM, RR=
__________CPM, SPO2=___________%
TIME >20mg. Furosemide given by NOD via IV pushed
>Oropharyngeal suctioning done by Dr. _________________
followed by extubation
TIME >Into recovery room per stretcher with same IVF of __________ @
__________cc level.