Republic of the Philippines

Province of Ilocos Sur

ILOCOS SUR PROVINCIAL HOSPITAL-GABRIELA SILANG
Vigan City

OPERATING ROOM RECORD

Name: ______________ Age: __________Sex: __________ Civil Status: _______

Ward: OPD No.:_________ Hospital No.: __________
Operating Diagnosis:

Surgeon: ___________________ First Assistant: ______________

Anesthesiologist: ____________________ Send Assistant: _______________
Anesthetic:________________ Time Anesthesia Begun: _________
Operating Date:__________________ Time Anesthesia Ended:__________
Operating Begun: ___ Surgical Nurse: __________________
Operating ended: __________ Circulating Nurse: ________________
Title of operation(s) Performed:

Tissue to Lab: ( ) Yes

( ) No
Description of Procedure:

Findings:

O.R. Medication Order: , MD

Sponge Count Verified

Signature
Drain:
Kind & Number

Comments