Soria, Kristine P. November 25-27, 2010

IV-3D WPDH/ OR

Caesarean Section Sample Charting

____> Into OR, per stretcher/ ambulatory, a __ y/o, female, with an ongoing IVF of D5LRS @

___cc level, infusing well @ left/ right hand.

>Checked consent for CS signed by the patient.

> Positioned comfortably to OR table.

> Hooked on cardiac monitor and oxisensor with initial vital signs taken as follows:

BP=__ mmHg, PR=__ bpm, RR=__ cpm, T˚=__ ˚C.

> Initial SpO2 reveals __%.

> Placed patient to side lying knee chest position.

____> Induction of anaesthesia done by Dr.______.

> Repositioned to supine with arms extended to sides.

> Initial instruments and sponge count done.

> Skin preparation aseptically.

> IFC inserted aseptically connected to UB.

____> Operation started.

____> Delivered to an alive baby boy/ girl via LTCS done by Dr._____.

____> Placenta delivered.

> Suctioning done intermittently.

> Exploration and manual evacuation of blood clots done.

> Final instruments, sharps, needles, and sponges count done complete.

____> Operation ended.

> Sterile pressure dressing applied after betadine painting on operation site.

> With urine output of ___cc.

> With latest vital signs as follows: BP=__ mmHg, PR=__ bpm, RR=__ cpm, T˚=__˚C.

> Endorsed for further care and management.

Soria, Kristine P. November 25-27, 2010

IV-3D WPDH/ OR

CTT Sample Charting

___> Into OR, a __ y/o, female/ male, per stretcher/ ambulatory, with an ongoing IVF of

D5LRS @ __cc level infusing well @ left/ right hand.

> With signed consent for CTT insertion.

> Positioned comfortably on OR table.

> Initial vital signs as follows: BP=___mmHg, PR=___ bpm, RR=__cpm, T˚=__˚C.

> Skin preparation done aseptically.

___> Induction of anaesthesia done by Dr.____.

___> Operation started.

> Incision on the left/ right side of the chest by Dr.____.

> With initial output of more or less ___cc.

___> Operation ended.

>Tubings well secured by Dr. ____.

___> Tubing clamped by Dr._____ and verbalized to unclamped after ___ hours/ mins.

> With latest vital signs as follows: BP=__mmHg, PR=__bpm, RR=__cpm, T˚=__˚C.

>Endorsed for further care and management.