Related Learning Requirements

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Related Learning Requirements

MAJOR NUMBER SIX


Name of Patient:_______________________________________________________________________
Date Assisted: ____________________________

Case Number: _________________________

Agency: _____________________________________________________________________________
Proposed Operation:
______________________________________________________________________________
______________________________________________________________________________

Operation Performed:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

Anesthesia (type, agents used):


______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

Name of Surgeon:

Given Name

Family Name

M.I.

Circulating Nurse: _____________________________________________________________________


Signature Over Printed Name
Clinical Instructor: _____________________________________________________________________
Signature Over Printed Name
Area Coordinator, Operating Room: _______________________________________________________
Signature Over Printed Name

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