Or Case Slips

Union Christian College Union Christian College
Widdoes St., Brgy IV, San Fernando City, La Union Widdoes St., Brgy IV, San Fernando City, La Union
OPERATING ROOM SLIP ( ) Scrub ( ) Circulating OPERATING ROOM SLIP ( ) Scrub ( ) Circulating
Name of student: ____________________________ Name of student: ____________________________
Name of patient: ____________________________ Name of patient: ____________________________
Case/Hospital Number: ____________________________ Case/Hospital Number: ____________________________
Age: ____________________________ Age: ____________________________
Diagnosis: ____________________________ Diagnosis: ____________________________
Operation Performed: ___________________________ Operation Performed: ___________________________
Date of Operation: ____________________________ Date of Operation: ____________________________
Anesthesia: ____________________________ Anesthesia: ____________________________
Surgeon: ____________________________ Surgeon: ____________________________
Name of Scrub Nurse: ____________________________ Name of Scrub Nurse: ____________________________
Signature of Scrub Nurse: ____________________________ Signature of Scrub Nurse: ____________________________
______________________ ______________________ ______________________ ______________________

Name & Signature of Name & Signature of Name & Signature of Name & Signature of
Clinical Instructor Nurse Supervisor Clinical Instructor Nurse Supervisor
Age: ____________________________ Age: ____________________________
Surgeon: ____________________________ Surgeon: ____________________________
______________________ ______________________ ______________________ ______________________

Age: ____________________________ Age: ____________________________
Surgeon: ____________________________ Surgeon: ____________________________
______________________ ______________________ ______________________ ______________________

Age: ____________________________ Age: ____________________________
Surgeon: ____________________________ Surgeon: ____________________________
______________________ ______________________ ______________________ ______________________

Age: ____________________________ Age: ____________________________
Surgeon: ____________________________ Surgeon: ____________________________
______________________ ______________________ ______________________ ______________________

Age: ____________________________ Age: ____________________________
Surgeon: ____________________________ Surgeon: ____________________________
______________________ ______________________ ______________________ ______________________

Age: ____________________________ Age: ____________________________
Surgeon: ____________________________ Surgeon: ____________________________
______________________ ______________________ ______________________ ______________________

Age: ____________________________ Age: ____________________________
Surgeon: ____________________________ Surgeon: ____________________________
______________________ ______________________ ______________________ ______________________

Age: ____________________________ Age: ____________________________
Surgeon: ____________________________ Surgeon: ____________________________
______________________ ______________________ ______________________ ______________________

Age: ____________________________ Age: ____________________________
Surgeon: ____________________________ Surgeon: ____________________________
______________________ ______________________ ______________________ ______________________

Age: ____________________________ Age: ____________________________
Surgeon: ____________________________ Surgeon: ____________________________
______________________ ______________________ ______________________ ______________________

Age: ____________________________ Age: ____________________________
Surgeon: ____________________________ Surgeon: ____________________________
______________________ ______________________ ______________________ ______________________

Age: ____________________________ Age: ____________________________
Surgeon: ____________________________ Surgeon: ____________________________
______________________ ______________________ ______________________ ______________________

Age: ____________________________ Age: ____________________________
Surgeon: ____________________________ Surgeon: ____________________________
______________________ ______________________ ______________________ ______________________

Age: ____________________________ Age: ____________________________
Surgeon: ____________________________ Surgeon: ____________________________
______________________ ______________________ ______________________ ______________________


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Union Christian College Union Christian College

Name of student: ____________________________ Name of student: ____________________________

Name of patient: ____________________________ Name of patient: ____________________________

Case/Hospital Number: ____________________________ Case/Hospital Number: ____________________________

Age: ____________________________ Age: ____________________________

Diagnosis: ____________________________ Diagnosis: ____________________________

Operation Performed: ___________________________ Operation Performed: ___________________________

Date of Operation: ____________________________ Date of Operation: ____________________________

Anesthesia: ____________________________ Anesthesia: ____________________________

Surgeon: ____________________________ Surgeon: ____________________________

Name of Scrub Nurse: ____________________________ Name of Scrub Nurse: ____________________________

Signature of Scrub Nurse: ____________________________ Signature of Scrub Nurse: ____________________________

______________________ ______________________ ______________________ ______________________

Name of student: ____________________________ Name of student: ____________________________

Name of patient: ____________________________ Name of patient: ____________________________

Case/Hospital Number: ____________________________ Case/Hospital Number: ____________________________

Age: ____________________________ Age: ____________________________

Diagnosis: ____________________________ Diagnosis: ____________________________

Operation Performed: ___________________________ Operation Performed: ___________________________

Date of Operation: ____________________________ Date of Operation: ____________________________

Anesthesia: ____________________________ Anesthesia: ____________________________

Surgeon: ____________________________ Surgeon: ____________________________

Name of Scrub Nurse: ____________________________ Name of Scrub Nurse: ____________________________

Signature of Scrub Nurse: ____________________________ Signature of Scrub Nurse: ____________________________

______________________ ______________________ ______________________ ______________________

Name of student: ____________________________ Name of student: ____________________________

Name of patient: ____________________________ Name of patient: ____________________________

Case/Hospital Number: ____________________________ Case/Hospital Number: ____________________________

Age: ____________________________ Age: ____________________________

Diagnosis: ____________________________ Diagnosis: ____________________________

Operation Performed: ___________________________ Operation Performed: ___________________________

Date of Operation: ____________________________ Date of Operation: ____________________________

Anesthesia: ____________________________ Anesthesia: ____________________________

Surgeon: ____________________________ Surgeon: ____________________________

Name of Scrub Nurse: ____________________________ Name of Scrub Nurse: ____________________________

Signature of Scrub Nurse: ____________________________ Signature of Scrub Nurse: ____________________________

______________________ ______________________ ______________________ ______________________

Name of student: ____________________________ Name of student: ____________________________

Name of patient: ____________________________ Name of patient: ____________________________

Case/Hospital Number: ____________________________ Case/Hospital Number: ____________________________

Age: ____________________________ Age: ____________________________

Diagnosis: ____________________________ Diagnosis: ____________________________

Operation Performed: ___________________________ Operation Performed: ___________________________

Date of Operation: ____________________________ Date of Operation: ____________________________

Anesthesia: ____________________________ Anesthesia: ____________________________

Surgeon: ____________________________ Surgeon: ____________________________

Name of Scrub Nurse: ____________________________ Name of Scrub Nurse: ____________________________

Signature of Scrub Nurse: ____________________________ Signature of Scrub Nurse: ____________________________

______________________ ______________________ ______________________ ______________________

Name of student: ____________________________ Name of student: ____________________________

Name of patient: ____________________________ Name of patient: ____________________________

Case/Hospital Number: ____________________________ Case/Hospital Number: ____________________________

Age: ____________________________ Age: ____________________________

Diagnosis: ____________________________ Diagnosis: ____________________________

Operation Performed: ___________________________ Operation Performed: ___________________________

Date of Operation: ____________________________ Date of Operation: ____________________________

Anesthesia: ____________________________ Anesthesia: ____________________________

Surgeon: ____________________________ Surgeon: ____________________________

Name of Scrub Nurse: ____________________________ Name of Scrub Nurse: ____________________________

Signature of Scrub Nurse: ____________________________ Signature of Scrub Nurse: ____________________________

______________________ ______________________ ______________________ ______________________

Name of student: ____________________________ Name of student: ____________________________

Name of patient: ____________________________ Name of patient: ____________________________

Name of student: Name of student:

Name of patient: Name of patient:

Case/Hospital Number: Case/Hospital Number:

Age: Age:

Diagnosis: Diagnosis:

Operation Performed: _ Operation Performed: _

Date of Operation: Date of Operation:

Anesthesia: Anesthesia:

Surgeon: Surgeon:

Name of Scrub Nurse: Name of Scrub Nurse:

Signature of Scrub Nurse: Signature of Scrub Nurse:

Name of student: Name of student:

Name of patient: Name of patient:

Case/Hospital Number: Case/Hospital Number:

Age: Age:

Diagnosis: Diagnosis:

Operation Performed: _ Operation Performed: _

Date of Operation: Date of Operation:

Anesthesia: Anesthesia:

Surgeon: Surgeon:

Name of Scrub Nurse: Name of Scrub Nurse:

Signature of Scrub Nurse: Signature of Scrub Nurse:

Name of student: Name of student:

Name of patient: Name of patient:

Case/Hospital Number: Case/Hospital Number:

Age: Age:

Diagnosis: Diagnosis:

Operation Performed: _ Operation Performed: _

Date of Operation: Date of Operation:

Anesthesia: Anesthesia:

Surgeon: Surgeon:

Name of Scrub Nurse: Name of Scrub Nurse:

Signature of Scrub Nurse: Signature of Scrub Nurse:

Name of student: Name of student:

Name of patient: Name of patient:

Case/Hospital Number: Case/Hospital Number:

Age: Age:

Diagnosis: Diagnosis:

Operation Performed: _ Operation Performed: _

Date of Operation: Date of Operation:

Anesthesia: Anesthesia:

Surgeon: Surgeon:

Name of Scrub Nurse: Name of Scrub Nurse:

Signature of Scrub Nurse: Signature of Scrub Nurse:

Name of student: Name of student:

Name of patient: Name of patient:

Case/Hospital Number: Case/Hospital Number:

Age: Age:

Diagnosis: Diagnosis:

Operation Performed: _ Operation Performed: _

Date of Operation: Date of Operation:

Anesthesia: Anesthesia:

Surgeon: Surgeon:

Name of Scrub Nurse: Name of Scrub Nurse:

Signature of Scrub Nurse: Signature of Scrub Nurse:

Name of student: Name of student:

Name of patient: Name of patient:

Case/Hospital Number: Case/Hospital Number:

Age: Age:

Diagnosis: Diagnosis:

Operation Performed: _ Operation Performed: _

Date of Operation: Date of Operation:

Anesthesia: Anesthesia:

Surgeon: Surgeon:

Name of Scrub Nurse: Name of Scrub Nurse:

Signature of Scrub Nurse: Signature of Scrub Nurse:

Name of student: Name of student:

Name of patient: Name of patient:

Case/Hospital Number: Case/Hospital Number:

Age: Age:

Diagnosis: Diagnosis:

Operation Performed: _ Operation Performed: _

Date of Operation: Date of Operation:

Anesthesia: Anesthesia:

Surgeon: Surgeon:

Name of Scrub Nurse: Name of Scrub Nurse:

Signature of Scrub Nurse: Signature of Scrub Nurse:

Name of student: Name of student:

Name of patient: Name of patient:

Case/Hospital Number: Case/Hospital Number: