OPEN CHOLECYSTECTOMY

DATE & TIME FOCUS DATA; ACTION; RESPONSE

______ Intraoperative care D: Into OR, a __year old__ per __
accompanied by ____ with ongoing IVF of
____ 1L at ____level infusing well on ___
hand.

A: Check consent for surgery.

 With an intact indwelling Foley catheter
draining well to _____ urine.
 Oriented to OR set-up.
 Assisted and placed comfortably into
the OR table.
 Connected to cardiac monitor with the
initial vital signs as follows: BP= _____
mmHg, PR= ____ bps, RR= _____ bps,
SPO2= ____ %.
 Skin preparation done by ________ by
painting betadine on the right subcostal
area extending to axilla just above the
symphysis pubis down to the sides.
 Aseptically draped by Dr.
____________.
 Initial sponge, instruments, and needle
count done by/with ______________.
______ Operation started  Operation started as a
_________incision initiated by Dr.
__________.
 Bleeders clamped and sponge.
 Gallbladder is grasped with a
______________ clamp.
 Cystic duct, cystic artery and common
bile duct are exposed.
 Specimen out characterized as a
____________ mass.
 Establish drainage at operative site.
 Final count of sponge, instruments, and
needle done by ____________.
 Wound closure by layer done by above
surgeon.
_______ End of operation  Operation finished.
 Cleaned and dressed wound aseptically
with betadine and top dressing.
 Latest vital signs as follows: BP=
______mmHg, PR= _____ bps, RR=
______bps, SPO2= _____ %.
  Post-operative care done.
_______ Unit transfer R: Brought to RR per stretcher accompanied by
___________ with on going IVF of ______ 1L
at _____ ml level infusing well on _____ hand.

. PACU care  Maintained on a __________ position,

no signs of swelling.
 Monitored vital signs and recorded
every _______.
 Applied ( Identify device )
_______________.
 Ensured safety and comfort.
R: Endorsed for further care and management.
or

_______ Unit transfer R: Transport to _____________ ward,

____________________, per stretcher with an
IVF of ______ __ L at _______ gtts/min.,
infusing well at the ____ hand and
accompanied by ___________ ; with latest
vital signs of BP= _____ mmHg, PR= ____
bps, RR= _____ bps, SPO2= _____ %. Aldrete
score of _____ ( & others e.g. drainage etc. )
_____________.