Date of Operation: Pre-Operative Diagnosis: Proposed Surgery:___________________

Surgeon: Anesthesiologist: Type of Anesthesia:__________________

Previous Surgery/ Date: ____________________________________________________________________________________
Blood Type: Height: cm. Weight:_________ kg.
Known Allergies: ( ) No ( ) Yes Drugs: Food: Others:______________________________
I. PREOPERATIVE ASSESSMENT
1. PHYSICAL
A. Neurological
Level of Consciousness: ( ) Conscious ( ) Coherent ( ) Sedated ( ) Comatose ( ) Others _________________

B. Cardiovascular
Blood Pressure: _____mmHg Cardiac Rate:_____/minute Heart Rhythm ( ) Regular ( ) Irregular
Murmur: Type: ( ) Systolic ( ) Diastolic Location:____________________
C. Respiratory
Respiratory Rate: _____/ minute
Breath Sounds: ( ) Clear ( ) Wheezes ( ) Rales/ Crackles ( ) Others ____________
Cough: ( ) Non – Productive ( ) Productive Secretions/ Color: __________________
D. Gastrointestinal
Abdomen: ( ) Normal ( ) Enlarged ( ) Rigid ( ) Others ___________________
Abdominal Pain: ( ) Absent ( ) Present Location: ( ) RUQ ( ) LUQ ( ) RLQ ( ) LLQ
Bowel Pattern: ( ) Regular ( ) Irregular, specify____________ ( ) Others ________________________________
Contraptions: ( ) None ( ) NGT ( ) Ostomy ( ) Others ________________________________
E. Genitourinary
Urinary Pattern: ( ) Normal ( ) Abnormal, specify__________________
Contraptions: ( ) None ( ) Foley Catheter ( ) Condom Catheter ( ) Wee Bag ( ) Others __________________
F. Musculoskeletal
ROM: ( ) Normal ( ) Weakness ( ) Paralysis ( ) Amputation ( ) AV Fistula □Right / □ Left
( ) RUE ( ) LUE ( ) RLE ( ) LLE
( ) Hemiplegic ( ) Paraplegic ( ) Quadriplegic
G. Integumentary
Skin Integrity: ( ) Intact ( ) Others___________________
Edema: ( ) None ( ) Yes Location:____________
Hematoma: ( ) None ( ) Yes Location:____________
H. Psychosocial/ Spiritual
Alcohol ( ) No ( ) Yes ( ) Occasional
Smoking ( ) No ( ) Yes _______pack/ year Stopped/ when: ___________
I. Spiritual
Chaplain’s Visit ( ) No ( ) Yes When:___________________
2. HEALTH HISTORY
A. Family Medical History ( ) Asthma ( ) CAD ( ) Hypertension ( ) DM
( ) CVA ( ) Cancer ( ) Others ___________________
B. Neonatal History (for Pediatric Patient)
Type of Delivery: ( ) Normal Spontaneous Delivery ( ) Caesarean Section
( ) Full Term ( ) Pre – Term
C. Special Precautions
( ) None Positive for: ( ) Hepatitis ( ) HIV ( ) PTB ( ) Others____________________
3. LABORATORY/ DIAGNOSTIC RESULTS
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
__________________________________________________________________________________________________________
Remarks:
____________________________________________________________________________________________________________
__________________________________________________________________________________________________________
____________________________________
Signature over printed name/ Date and time
Perioperative Nurse
Family Name: First Name: Middle Name:
________________________________________________________
PHILIPPINE HEART CENTER Age: Sex: Date of Birth:____________
East Avenue, Quezon City Hospital No.: _______Room No._____________________
PERIOPERATIVE NURSING RECORD Attending Physician:_______________________________________
II. ADMISSION TO OR (Assessment)
Date: ______________ Time: _____________ Unit of Origin: _____________ Mode of Transport: ___________________________
Patient Identification Band: ( ) Yes ( ) No Nature of Procedure: ( ) Elective ( ) Emergency
Antibiotic Prophylaxis: ________________________________________________________________________ Time: ________
1. Level of Consciousness: ( ) Awake ( ) Conscious ( ) Sedated ( ) Unconscious
2. Integumentary: ( ) Intact ( ) Others ____________ Color: ( ) Normal ( ) Jaundice ( ) Pale ( ) Cyanotic
Hematoma: ( ) No ( ) Yes Location: ___________________________________
3. Therapeutic Adjuncts: IVF/ Rate: _____________________ ____________________ Site: _______________ Gauge: _________
Supports: (1) ___________________ (2) ___________________ (3) __________________ (4) ________________
Blood Products: __________________________________ Others:_____________________________________
___________________________________________ _____________________________________
Name / Signature of Endorsing Nurse/ Date/ Time Name and Signature of OR Nurse/ Date/ Time
III. INTRAOPERATIVE RECORD
A. Contraptions B. Contraptions Label
( ) 1. Oxygen Inhalation: ( ) Nasal Cannula ( ) Mask Right Left Left Right
( ) Intubated Size: ______ Depth: _____
( ) 2. CVP/ PA Catheter Type: ____lumen
( ) 3. ECG
( ) 4. A-Line
( ) 5. IV Line
( ) 6. Dispersive Electrode Ground Pads
( ) 7. Foley Catheter/ Wee Bag
( ) 8. Site of Operation
( ) 9. Chest Tube
( ) 10. Wound Drainage
( ) 11. IABP
C. Position
( ) Supine ( ) Lateral □Right / □ Left ( ) Prone ( ) Lithotomy FRONT BACK
D. Induction of Anesthesia
1. Anesthesiologists: ____________________ _____________________ _______________________ _____________________
2. Anesthesia: Started: _____________ Ended: ______________
( ) GA-Inhalation ( ) GA-TIVA ( ) Local ( ) Monitored Anesthesia Care ( ) Regional-Spinal ( ) Regional-Epidural
E. Start of Surgery
1. Surgeons: _____________________ _______________________ ________________________ ________________________
_____________________ _______________________ ________________________ ________________________
2. Scrub Nurse: _______________________________ Circulating Nurse: ___________________________________
Reliever/Time: _______________________________ Reliever/ Time: ____________________________________
3. Cutting Time: Started: _____________ Ended: ______________
Site: ( ) Midsternotomy ( ) Thoracotomy □Right / □ Left ( ) Others __________________________
On bypass at ________ Cross clamp on at ________ Cross clamp off at _________ Off bypass at __________
4. Electrosurgical Unit: Brand/ Machine Number: ___________________ Rm #: _____ Cutting: _____ Coagulation: _____
5. Operation Performed: ________________________________________________________________________________________
6. Prosthesis/ Implant: _________________________________________________________________________________________
7. Defibrillation Joules/ Time ______ x ____________ ; ______ x ___________ ; ______x___________
8. Specimen (specify): _______________ ( ) Histopath ( ) GS ( ) CS ( ) Cytology ( ) Frozen Section/Time sent __________
F. Parameters: Initial Latest Initial Latest
__________________ BP _____________________ _________________ CVP____________________
__________________ HR ____________________ __________________ Na _____________________
__________________ ECG____________________ __________________ K ______________________
G. Skin Integrity Description: _________________________________________________________________________________
IV. POSTOPERATIVE RECORD
A. Level of Consciousness: ( ) Conscious ( ) Sedated ( ) Unconscious ( ) Others ____________________
B. Contraptions
( ) 1. Intubated ( ) Extubated: ( ) Oxygen Facemask at ______ ( ) Nasal Cannula at _______ ( ) Tracheostomy
( ) 2. IVF _____________________ Supports: _____________________________________________________________________
( ) 3. Blood Transfusion ( ) Remaining Blood/ Blood Components: ________________________________________________
( ) 4. A-Line ( ) CVP ( ) PA Catheter ( ) Pacing Wire ( ) IABP ( ) Others _______________
( ) 5. Chest tube Size: ______ ( ) Wound Drainage ( ) Foley Catheter: _______ ml ( ) Wee Bag: _______ ml
( ) 6. Patient Record ( ) PDS/ ID band ( ) OR Record ( ) Anesthesia Record ( ) OR Blood Screening Results
( ) Blood Transfusion Sheet ( ) Perioperative Nursing Record ( ) Extracorporeal Record ( ) Clinical Pathway
( ) Imaging/ Coro-Angio/ Plates endorsed to _______________ Relationship_________ ( ) Others____________________
C. Remarks: ________________________________________________________________________________________________
_______________________________________ _______________________________________________
Name / Signature of OR Nurse/ Date/ Time Name / Signature of Receiving Nurse/ Date/ Time/ Unit