Nagcarlan District Hospital: Operation Records

Republic of the Philippines
Provincial Government of Laguna
LPH - NAGCARLAN DISTRICT HOSPITAL

“Philhealth Accredited Health Care Provider”
Nagcarlan, Laguna / Tel. No. (049) 563-1014/563-1016
OPERATION RECORDS
NAME:_______________________________________ AGE:____ SEX:_________ CIVIL STATUS:___________

WARD:_____________________ BED NUMBER:___________ HOSPITAL NUMBER:____________________
PRE-OPERATIVE DIAGNOSIS:_________________________________________________________________
FINAL DIAGNOSIS:
__________________________________________________________________________
_________________________________________________________________________________________
SURGEON:__________________________________ 1ST ASSIST:_____________________________________
ANESTHESIOLOGIST:________________________________ 2ND ASSIST:______________________________
ANESTHETIC AGENT:___________________________ TIME ANESTHESIA BEGAN:______________
A.M./P.M.
OPERATON DATE:_____________________________ TIME ANESTHESIA ENDED:______________
A.M./P.M.
TIME OPERATION BEGAN:_____________ A.M./P.M. TIME OPERATION ENDED:_____________
A.M./P.M.
SURGICAL NURSE:___________________________ CIRCULATING
NURSE:_____________________________
TITLE OF OPERATIONS PERFORMED: ELECTIVE EMERGENCY SUCTION CURETTAGE
TISSUE TO LAB: YES ( ) NO( ) SPONGES/INSTRUMENTS/NEEDLES VERIFIED TIME/BY:__________________
1ST_____________ COMPLETE 2ND______________COMPLETE
Induction of ________________ anesthesia. OPERATIVE FINDINGS:
Patient placed in dorsal lithotomy position.
Perineal swab
Bladder Catheterization and internal examination
done revealing _____________________________
__________________________________________
Asepsis and antisepsis technique done then sterile

drapes applied.
Application of the posterior vaginal retractor to
visualize the cervix.
Anterior lip of the cervix gently grasped with
tenaculum forceps.
Suction curettage done obtaining about _________
cc of vesicular tissues admixed with blood clots.
Ovum curettage followed by blunt and sharp
curettage at the endometrial cavity obtaining
minimal amount of curettings.
Initial and Final Hysterometry= ____________ cm.
Removal of instruments.
Patient tolerated the procedure well.
Estimated blood loss: ______________ cc.
SURGEON


OPERATION RECORDS

FINAL DIAGNOSIS:
__________________________________________________________________________
_________________________________________________________________________________________
A.M./P.M.
A.M./P.M.
A.M./P.M.
NURSE:_____________________________
TITLE OF OPERATIONS PERFORMED: ELECTIVE EMERGENCY TOTAL ABDOMINAL HYSTEROCOTOMY
WITH BILATERAL SALPHINGO-OOPHORECTOMY
Patient placed on the supine position after induction Both infundibulopelvic ligaments were triply
of anesthesia. clamped , incised and suture ligated with Vicryl 1-0
Perineal swab and Bladder Catheterization done catgut.
Internal examination done revealing Skeletonization done and uterine vessels triply
____________________________________________ clamped , incised and suture ligated with Vicryl 1-0
__________________________________________ catgut.
Uterosacral ligaments triply clamped , incised and
Asepsis and antisepsis technique done then sterile suture ligated with Vicryl 1-0 catgut.
drapes applied. Cardinal ligaments triply clamped , incised and
Median longitudinal infra-umbilical incision done on suture ligated with Vicryl 1-0 catgut in series up to
the skin and carried down to the fascia. the cervico-vaginal junction.
Recti muscles splitted longitudinally then peritoneum Cervico-vaginal junction identified curved clamps
entered and pelvic organs exposed. applied on both sides then uterus was removed by
Abdominal retractor applied and bowels packed with cutting above the clamps.
warm and moist gauze. Allis forceps applied on the anterior, posterior and
The pathology was identified as the lateral vaginal cuffs edges.
__________________ Alcoholized gauze inserted to he vagina. Figure of
eight sutures using Vicryl 1-0 catgut placed on the
Round ligaments clamped then suture ligated with angles of the vaginal cuffs anchoring them to the
Vicryl 1-0 catgut and then cut. cardinal and uterosacral ligaments.
Leaves of the broad ligaments opened anteriorly and Reefing of the vaginal edges with continuous
posteriorly with Metzenbaum scissors. interlocking sutures using Vicryl 1-0 catgut.
Vesico-peritoneal fold elevated and incised and Peritoneal cavity washed and cleansed with sterile
bladder dissected of the lower uterine segment by gauze. Bleeders checked and ligated.
sharp and blunt dissection.


OPERATION RECORDS

FINAL DIAGNOSIS:
__________________________________________________________________________
_________________________________________________________________________________________
A.M./P.M.
A.M./P.M.
A.M./P.M.
NURSE:_____________________________
TITLE OF OPERATIONS PERFORMED: ELECTIVE EMERGENCY LOW TRANSVERSE CAESAREAN SECTION
Induction of ________________ anesthesia. Spontaneous and complete extraction of the placenta
Patient placed in supine position. from its ________________________ location.
Perineal swab and Bladder Catheterization done Uterine cavity cleansed with sterile gauze.
Internal examination done revealing Closure of the uterus in 3 layers:
______________________________________________ 1st layer -continuous interlocking suture using Chromic 1-
_ 0 catgut.
______________________________________________ 2nd layer -continuous interlocking suture using Chromic 1-
_ 0 Catgut.
3rd layer - simple continuous suture using Chromic 2-0
Asepsis and antisepsis technique done then sterile catgut.
drapes applied. Bleeders checked and ligated.
Midlne infra-umbilical incision done on the skin and Adnexae inspected revealing grossly normal finding
carried down to the fascia. Moist pack removed.
Recti muscles splitted longitudinally then peritoneum Counting of instruments, needles and sponges --
entered COMPLETE
Exposing a gravid uterus with well-formed lower uterine Closure of the abdominal wail layer by layer:
segment. Peritoneum -simple continuous suture using Chromic 2-0
Bladder retracted downwards, vesico-uterine flap Fascia - continuous interlocking suture using Vicryl 1-0.
created. Subcutaneous - simple continuous suture using Plain 2-0
Moist pack placed on the lateral gutters on each side of Skin — subcuticular suture using Vicryl 2-0.
the uterus. Sterile top dressing applied.
Curvilinear transverse incision done on the lower uterine Evacuation of blood clots per vagina.
segment layer then bag of water ruptured revealing Patient tolerated the procedure well.
_______________________ amniotic fluid. Estimated blood loss= ______________ cc.
An alive baby __________ in __________ position.
Delivered by scooping the head and traction of the body ________________
Ballard score__________ wks. Apgar score:_________. SURGEON
Umbilical cord doubly clamped and then cut in between.


OPERATION RECORDS

FINAL DIAGNOSIS:
__________________________________________________________________________
_________________________________________________________________________________________
A.M./P.M.
A.M./P.M.
A.M./P.M.
NURSE:_____________________________
TITLE OF OPERATIONS PERFORMED: ELECTIVE EMERGENCY CLASSICAL CAESAREAN SECTION
FOLLOWED BY BILATERAL TUBAL LIGATION VIA MODIFIED POMEROY TECHNIQUE.
Patient placed in supine position after Induction of An alive baby __________ in __________ position.
________________ anesthesia. Delivered by scooping the head and traction of the body.
Perineal swab and Bladder Catheterization done Ballard score__________ Apgar score:_________.
Internal examination done revealing Umbilical cord doubly clamped and then cut in between.
______________________________________________ Spontaneous and complete extraction of the placenta
_ from its ________________________ location.
______________________________________________ Uterine cavity cleansed with sterile gauze.
_ Closure of the uterus in 2 layers:
1st layer -continuous interlocking suture using Chromic 1-
Asepsis and antisepsis technique done then sterile 0 catgut.
drapes applied. 2nd and 3rd layer -continuous interlocking suture using
Midlne infra-umbilical incision done on the skin and Chromic 1-0 Catgut.
carried down to the fascia. Bleeders checked and ligated.
Recti muscles splitted longitudinally then peritoneum Adnexae inspected revealing grossly normal finding
entered Proceeded to do bilateral tubal ligation via Modified
Exposing a gravid uterus with well-formed lower uterine Pomeroy.
segment. Moist pack removed. Counting of instruments, needles
Bladder retracted downwards, vesico-uterine flap and sponges -- COMPLETE
created.
Moist pack placed on the lateral gutters on each side of
the uterus.
Curvilinear transverse incision done on the lower uterine
segment layer then bag of water ruptured revealing
_______________________ amniotic fluid.


OPERATION RECORDS

FINAL DIAGNOSIS:
__________________________________________________________________________
_________________________________________________________________________________________
A.M./P.M.
A.M./P.M.
A.M./P.M.
NURSE:_____________________________
TITLE OF OPERATIONS PERFORMED: Postpartum Bilateral Tubal Ligation Via Pomeroy Technique under
Intravenous-Local Anesthesia
Patient placed in supine position. Right Fallopian tube is ently pulled out until the fimbra is
Induction of IV sedation visualized via “walking through” the tube.
Asepsis and antisepsis technique The loop of the tube was tied using Chromic 2.0
Sterile drapes applied. The loop of the tube was cut above the knot using
Internal examination done: cervix admits 2 fingers, Metzenbaum scissors leaving at least 0.5cm tubal
uterus well contracted, nc palpable adnexal mass, stomp above the knot.
minimal vaginal bleeding.
Infiltration of local anesthesia Bleeders checked and ligated, hemostasis achieved
Transverse infra-umbilical incision done Counting of instruments, needles and sponges --
Blunt dissection of the subcutaneous up to the Fascia COMPLETE
using Kelly Forceps Closure of the abdominal wail layer by layer:
Fascia is grasped using Kelly Forceps then incision of Peritoneum -simple continuous suture using Chromic 2-0
Fascia - continuous interlocking suture using Vicryl 1-0.
fascia then peritoneum entered.
Subcutaneous - simple continuous suture using Plain 2-0
Retractor applied.
Skin — subcuticular suture using Vicryl 2-0.
Left Fallopian tube is gently pulled out until the fimbra
Sterile top dressing applied.
is visualized via “walking through” the tube. Evacuation of blood clots per vagina.
Forceps is placed at the midsection of the tube, about Patient tolerated the procedure well.
2-3 cm from the communal portion of the tube. Estimated blood loss= ______________ cc.
The loop of the tube was tied using Chromic 2.0
The loop of the tube was cut above the knot using ________________
Metzenbaum scissors leaving at least 0.5cm tubal SURGEON
stomp above the knot.
Right Fallopian tube identified and grasped using Kell
forceps.


OPERATION RECORDS
DILATATION AND CURETTAGE
PATIENT NAME: ___________________________________ AGE:_____ SEX:_________

STATUS:___________
ADDRESS:__________________________________________________ DATE:_________________________
PRE-OP DIAGNOSIS:________________________________________________________________________
POST-OP DIAGNOSIS:_______________________________________________________________________
ANESTHESIA/ANALGESIA:____________________________________________________________________
TIME OF INDUCTION:____________________________________
START OF OPERATION:____________________________ END OF
OPERATION:_________________________
SURGEON:___________________________________
ASSIST:____________________________________
OPERATIVE FINDINGS AND TECHNIQUE:

IV sedation
Asepsis and antisepsis technique
Bladder catheterization
Application of posterior vaginal retractor
Graspin of anterior lip of the cervix using tenaculum forcep
Endocervical curetting obtained
Insertion of hysterometer- uterine depth measured=______cm
Endometrial curetting obtained
Fishing out of ____________ using ovum forcep amounting to ____________
Blunt and shar curettage done
Removal of instruments
Applying povidone-iodine
Cleaning of the perineum
Specimen sent for histopath
___________________________, MD
Surgeon

OPERATION RECORDS

FINAL DIAGNOSIS:
__________________________________________________________________________
_________________________________________________________________________________________
A.M./P.M.
A.M./P.M.
A.M./P.M.
NURSE:_____________________________
TITLE OF OPERATIONS PERFORMED: ELECTIVE EMERGENCY RIGHT LEFT SALPHINGO-
OOPHORECTOMY
Patient placed in supine position after Induction of Right Left fallopian tube, suspensory ligament and
________________ anesthesia. mesosalpinx are transected and the right left fallopian
Perineal swab and Bladder Catheterization done tube and ovary were removed
Internal examination done revealing Bleeders checked and ligated.
_________________________________________________ Peritoneal washing done
_________________________________________________ Moist gauze and abdominal retractor removed.
Asepsis and antisepsis technique done then sterile drapes Counting of instruments, needles and sponges -- COMPLETE
applied. Closure of the abdominal wail layer by layer:
Median infra-umbilical incision done on the skin and carried Peritoneum -simple continuous suture using Chromic 2-0
done to the fascia. Fascia - continuous interlocking suture using Vicryl 1-0.
Recti muscles splitted longitudinally then peritoneum Subcutaneous - simple continuous suture using Plain 2-0
entered Skin — subcuticular suture using Vicryl 2-0.
Suctioning of hemoperitoneum of about _____________cc. Sterile top dressing applied.
The pathology was identified as the ___________________ Patient tolerated the procedure well.
_________________________________________________ Estimated blood loss= ______________ cc.
Abdominal retractor applied. Bowels were packed with ________________

warm moist gauze. SURGEON
Bladder retracted downwards.
Right Left infundibulo-pelvic ligament is triply clamped,
incised between the first and second clamps, tied with
Chromic 1-0 catgut then sutured again.
Right Left suspensory ligament of the ovary and the
fallopian tube is triply clamped, incised between the 1 st and
2nd clamps, tied with Chromic 1-0 catgut then sutured again.


OPERATION RECORDS

FINAL DIAGNOSIS:
__________________________________________________________________________
_________________________________________________________________________________________
A.M./P.M.
A.M./P.M.
A.M./P.M.
NURSE:_____________________________
TITLE OF OPERATIONS PERFORMED: ELECTIVE VAGINAL HYSTERECTOMY WITH ANTERIOR AND POSTERIOR
REPAIR
Induction of __________________anesthesia. Peritoneal vesico-uterine incised with Metzenbaum
Patient placed on dorsal lithotomy position. scissors and anchored with Vicryl 1-0; a narrow
Bladder Catheterization done and vaginal swabbing retractor inserted into the peritoneal cavity holding
done. the bladder cephalad.
Inspection of the vagina, there is marked rolling of the Perirectal fascia pushed cephalad entering the
anterior and posterior vaginal walls. posterior cul-de-sac where an index finger was
Internal examination done revealing inserted to examine for any adhesions or bowel.
_________________________________________________ The uterosacral ligaments clamped, incised and suture
_________________________________________________ ligated with Vicryl 1-0 catgut and tagged.
_________________________________________________ Cardinal ligaments on both sides clamped, incised,
Asepsis and antisepsis technique done then sterile and suture ligated using Vicryl1-0.
drapes applied. The upper portion of he cardnal ligaments and its
Both lower one-third of the labia majora stay sutured uterine vessels clamped, incised, suture ligated with
to the medial thighs on each side. Vicryl 1-0 catgut.
Anterior lip of the cervix grasped with Allis forceps The uterine fundus was pulled out through the
and pulled out of the introitus. anterior opening.
Transverse incision made through the vaginal mucosa Utero-ovarian ligaments, uterine end of the tubes and
above the pubo-vesical and perirectal fascia broad ligaments on both sides triple clamped and
Cephalad up to the vesico-uterine fold. incised and suture ligated using Vicryl 1-0 catgut, then
tagged with clamp. Uterus was removed.
Inspection and palpation of both adnexae –
UNREMARKABLE.


OPERATION RECORDS

FINAL DIAGNOSIS:
__________________________________________________________________________
_________________________________________________________________________________________
A.M./P.M.
A.M./P.M.
A.M./P.M.
NURSE:_____________________________
TITLE OF OPERATIONS PERFORMED: ELECTIVE EMERGENCY RIGHT LEFT SALPHINGO-
OOPHORECTOMY
Patient placed in supine position after Induction of Kelly clamps applied on the base and cut using Metzenbaum
________________ anesthesia. scissors and suture ligated using Chromic 1-0 sequential
Perineal swab and Bladder Catheterization done until the myoma was totally removed.
Internal examination done revealing Several layers of figure of eight sutures using Chromic 2-0
_________________________________________________ catgut done on the myometrium to obliterate dead spaces.
_________________________________________________ Uterine serosa approximated using continuous interlocking
Asepsis and antisepsis technique done then sterile drapes Chromic 2-0 catgut.
applied. Bleeders checked and ligated.
Median longitudinal infraumbilical incision done on the skin Moistened packs are removed, peritoneal washing done.
and carried down to the fascia. Abdominal retractor removed.Counting of instruments,
Rectus muscles splitted longitudinally then peritoneum needles and sponges -- COMPLETE
entered. Closure of the abdominal wail layer by layer:
The pathology was identified as the ___________________ Peritoneum -simple continuous suture using Chromic 2-0
_________________________________________________ Fascia - continuous interlocking suture using Vicryl 1-0.
Abdominal retractor applied. Bowels were packed with Subcutaneous - simple continuous suture using Plain 2-0
warm moist gauze. Skin — subcuticular suture using Vicryl 2-0.
Abdominal retractor applied and bowels are packed with Sterile top dressing applied.
warm and moist gauze. Patient tolerated the procedure well.
Bladder retracted downwards. Estimated blood loss= ______________ cc.
A vertical incision is made in the ______________________
serosal surface of the uterus through the myometrium down ________________
to the myoma. SURGEON
An Allis clamp is applied to one edge of the incision, and the
incision is elevated. Plane of the cleavage and the
surrounding myometrium identified.
Mosquito forceps and a finger are used to sweep the
myometrium off the myoma.
A towel clip is used to grasp the myoma and traction and/or
counter-traction is used to elevate the myoma out of the
myometrium until the pedicle is reached.


OPERATION RECORDS

POST-OPERATIVE DIAGNOSIS: ________________________________________________________________
ANESTHETIC:_________________________________ TIME ANESTHESIA BEGAN:______________
A.M./P.M.
A.M./P.M.
TIME OPERATION BEGAN:___________ A.M./P.M. SURGICAL NURSE:_______________________________
TIME OPERATION ENDED:___________ A.M./P.M. CIRCULATING NURSE:_____________________________
TITLE OF OPERATION(S) PERFORMED:__________________________________________________________
_________________________________________ TISSUE TO LAB: YES ( ) NO( )
Description of Procedure: Asepsis and Antisepsis technique

Patient in supine position
Induction of Spinal Anesthesia
Operative site prepared and drapes applied
Vertical midline suprapubic incision made on skin
and carried down to the peritoneum
Identification of the effected tube
Mesosalphinx of fallopian tube successively
clamped and cut until tube is completely excised
Findings: Each pedicle ligated using chromic 1.0 absorbable

suture
Suctioning of hemoperitoneum and evacuation of
blood clots
Abdominal wall closed in anatomic layers
Sterile dressing applied
___________________________, MD
Surgeon


OPERATION RECORDS

POST-OPERATIVE DIAGNOSIS: ________________________________________________________________
ANESTHETIC:_________________________________ TIME ANESTHESIA BEGAN:______________
A.M./P.M.
A.M./P.M.
TIME OPERATION BEGAN:___________ A.M./P.M. SURGICAL NURSE:_______________________________
TIME OPERATION ENDED:___________ A.M./P.M. CIRCULATING NURSE:_____________________________
TITLE OF OPERATION(S) PERFORMED:__________________________________________________________
_________________________________________ TISSUE TO LAB: YES ( ) NO( )
Description of Procedure Patient in supine position

Induction of Spinal Anesthesia
Asepsis and Antisepsis technique
Operative site prepared and drapes applied
Vertical midline suprapubic incision made on skin
and carried down to the peritoneum
Findings: Gangrenous ovary with double twist on the

pedicle noted
Mass exteriorized and triple clamp applied on
twisted pedicle
Incision made between clamps till the tube and
ovarian mass are removed
Chromic 1 absorbable sutures placed on stamps
Rest of pelvic sutures inspected
Abdominal wall closed in anatomic layers
Sterile dressing applied
___________________________, MD
Surgeon

Nagcarlan District Hospital: Operation Records

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Republic of the Philippines

Provincial Government of Laguna

LPH - NAGCARLAN DISTRICT HOSPITAL

NAME:_______________________________________ AGE:____ SEX:_________ CIVIL STATUS:___________

Asepsis and antisepsis technique done then sterile

Republic of the Philippines

LPH - NAGCARLAN DISTRICT HOSPITAL

NAME:_______________________________________ AGE:____ SEX:_________ CIVIL STATUS:___________

Republic of the Philippines

LPH - NAGCARLAN DISTRICT HOSPITAL

NAME:_______________________________________ AGE:____ SEX:_________ CIVIL STATUS:___________

Republic of the Philippines

LPH - NAGCARLAN DISTRICT HOSPITAL

NAME:_______________________________________ AGE:____ SEX:_________ CIVIL STATUS:___________

Republic of the Philippines

LPH - NAGCARLAN DISTRICT HOSPITAL

NAME:_______________________________________ AGE:____ SEX:_________ CIVIL STATUS:___________

Republic of the Philippines

LPH - NAGCARLAN DISTRICT HOSPITAL

PATIENT NAME: ___________________________________ AGE:_____ SEX:_________

OPERATIVE FINDINGS AND TECHNIQUE:

LPH - NAGCARLAN DISTRICT HOSPITAL

NAME:_______________________________________ AGE:____ SEX:_________ CIVIL STATUS:___________

Abdominal retractor applied. Bowels were packed with ________________

Republic of the Philippines

LPH - NAGCARLAN DISTRICT HOSPITAL

NAME:_______________________________________ AGE:____ SEX:_________ CIVIL STATUS:___________

Republic of the Philippines

LPH - NAGCARLAN DISTRICT HOSPITAL

NAME:_______________________________________ AGE:____ SEX:_________ CIVIL STATUS:___________

Republic of the Philippines

LPH - NAGCARLAN DISTRICT HOSPITAL

NAME:_______________________________________ AGE:____ SEX:_________ CIVIL STATUS:___________

Description of Procedure: Asepsis and Antisepsis technique

Findings: Each pedicle ligated using chromic 1.0 absorbable

Republic of the Philippines

LPH - NAGCARLAN DISTRICT HOSPITAL

NAME:_______________________________________ AGE:____ SEX:_________ CIVIL STATUS:___________

Description of Procedure Patient in supine position

Findings: Gangrenous ovary with double twist on the

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