Form No.

Hospital No.:

Case No.:

Room No.:

SURGICAL MEMORANDUM

Date of Operation: __________________

Name of Patient: ______________________________________________________ Age: ________ Sex: ________
Pre-Operative Diagnosis: _____________________________________________ Height:_________ Weight:_________
Post-Operative Diagnosis: ____________________________________________________________________________
Surgeon: _________________________________ Assistant Surgeon: ______________________________________
Anesthesiologist: ___________________________________________________________________________________
Anesthetic Agent: ____________________________________ Quantity: _____________________________________
Anesthesia Started: _____________________________________Anesthesia Finished: ___________________________
Operation Started: ________________________________ Operation Finished: _________________________________
Instrument Nurse: _________________ Sponge Nurse: _____________________ Sponge Count Verified: __________
Treatment Given In the Operating Room: ________________________________________________________________
Induction: _________________________________________________________________________________________
Intra-Operative:_____________________________________________________________________________________
Post-Operative:_____________________________________________________________________________________
Operation Performed: _______________________________________________________________________________
Complications: _____________________________________________________________________________________

Baby Out: ________ Sex: _________ Apgar Score: __________ Weight: ___________ Position: ____________
Specimen Forwarded to Laboratory for Examination: ______________________________________________________
Operative Technique/Findings:
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________

__________________________________, MD _________________________________, MD
Signature over Printed Name Signature over Printed Name
(ANESTHESIOLOGIST) ( SURGEON)
License No._________________________ License No.________________________
Date & Time: ____________________________ Date & Time: ___________________________