VICENTE SOTTO MEMORIAL MEDICAL CENTER

NURSING DIVISION
JOB ORDER STAFF MONTHLY ACCOMPLISHMENT REPORT
OPERATING ROOM

DECEMBER 1-31, 2018

ACTIVITIES

I. Assessment
1. Established rapport to patients.
2. Obtained and checked nursing history through interview and physical assessment.
3. Interviewed and verified consent.
4. Identified subjective and objective problems of patients.
5. Detected abnormalities from the assessment and results of diagnostic examinations and results.

II. Planning
1. Prioritized needs and problems of the patient.
2. Prepared materials and supplies needed for the procedure.
3. Formulated nursing care program.
4. Planned nursing intervention for patients intra-operatively.

III. Implementation
1. Carried out plan of care
2. Administered prescribed treatment.
3. Administered preoperative and intra-operative medications as ordered.
4. Followed the principles of asepsis and maintained sterility at all times.
5. Anticipated the needs of the patient and the surgical team.
6. Gave health teachings to patients.
7. Provided social, emotional, psychological, and spiritual support.
8. Maintained a therapeutic environment.

IV. Evaluation
1. Evaluated effects of nursing care
2. Notified immediate superiors of unusual, untoward, difficult situations conditions
3. Revised plan of care as necessary

V. Documentation
1. Recorded assessment, interventions and evaluation of nursing care.

Prepared by: Noted by:

FRANCENE JOYCE O. SEPULVEDA, RN _____________________

Name/Signature Name/Signature
JO Nurse I OR Nurse III Supervisor

Approved by:

MRS. CONSUELO B. TECLING, RN

CLUSTER 1 COORDINATOR

DOH-VSMMC-NSD-F-211 Rev. 0