Sample Chartings
3
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.
Transcript of Sample Chartings
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.
