NSGOR-FM-007/REV.

0/1Jul2015

MAYOR HLARION A. RAMIRO SR. REGIONAL

TRAINING & TEACHING HOSPITAL
Maningcol, Ozamiz City

OPERATING ROOM REQUISITION SLIP

Station/Ward : _________________ Date:________________

Shift: _______________________
Census: ______________________
Requested by:
QTY UNIT ARTICLE QTY UNIT ARTICLE
Abdominal Pack 8x36x12 FBC fr. 18 (2 way)
Abdominal pack 8x12x12 FBC fr. 18 ( 3way)
Absorbable Gelatin Sponge FBC fr. 24 (3 way)
Airway Guedel (Neonate) Gauze Sponge 4x8, 28x24 mesh
Airway Guedel Adult (Red) Gloves 6.5
Approved by:
Airway Guedel Adult (Black) Gloves 7.0
Airway Guedel Adult (Green) Gloves 7.5
Airway Guedel Adult (Orange)
____________________________ Gloves 8.0
Airway Guedel Adult (White) Incised Drape 42x40cm
Airway Guedel Adult (Yellow) Incised Drape 56x45cm
Asepto Syringe I.V cannula G.18
Blood Transfusion Set I.V cannula G.20
_____________________________
Bone Wax I.V cannula G.22
Cautery Pencil I.V cannula G.24
Nurse on Duty (NameCautery Pad
& Signature) Laryngeal Mask Airway #1.0
Chromic O Round Laryngeal Mask Airway #1.5
Chromic 1 Round 75 cm Laryngeal Mask Airway #2.0
Chromic 2-0 75cm Laryngeal Mask Airway #2.5
Chromic 3-0 Round Laryngeal Mask Airway #3.0
Chromic 4-0 Round Laryngeal Mask Airway #3.5
Head Nurse/Supervisor
Colostomy Bag (Pedia) Laryngeal Mask Airway #4.0
Colostomy Bag ( Adult) Laryngeal Mask Airway #5.0
Endotracheal Tube #2.5 NGT fr.5
Endotracheal Tube #3.0 NGT fr.8
Endotracheal Tube #3.5 NGT fr.10
Endotracheal Tube #4.0 NGT fr.12
NSGOR-FM-007/REV.0/1Jul2015
Endotracheal Tube #4.5 NGT fr.14
Endotracheal Tube #5.0 NGT fr.16
Endotracheal Tube #5.5 NGT fr.18
Endotracheal Tube #6.0 O2 Cannula ( Adult)
Endotracheal Tube #6.5 O2 Cannula (Pedia)
Endotracheal Tube #7.0 Orthopedic Gloves 7.5
Endotracheal Tube #7.5 Orthopedic Gloves 8.0
Endotracheal Tube #8.0 Penrose Drain 1”
Epidural Catheter Penrose Drain ½”
FBC fr. 8 (2way) Post Op Wound Dressing 20x10cm
FBC fr. 10 (2way) Post Op Wound Dressing 15.8x8.5cm
FBC fr. 12 (2way) Polypropylene 0
FBC fr. 14 (2way) Polypropylene 2-0
FBC fr. 16 (2way) Polypropylene 3-0

MAYOR HLARION A. RAMIRO SR. REGIONAL

TRAINING & TEACHING HOSPITAL
Maningcol, Ozamiz City

OPERATING ROOM REQUISITION SLIP

Station/Ward : _________________ Date:________________

Shift: _______________________
Census: ______________________
Requested by:
QTY UNIT ARTICLE QTY UNIT ARTICLE
Polypropylene 4-0 Surgical Blade #20
Polypropylene 6-0 Surgical Brush w/ Providone Iodine
Polypropylene Mesh 8x15cm Syringe 1cc
Polyglycholic Acid Suture Liver Suture Syringe 2cc/3cc
Polyglycholic Acid Suture 0 Syringe 5cc
Approved by:
Polyglycholic Acid Suture 1 Syringe 10cc
Polyglycholic Acid Suture 2-0 75cm Syringe 20cc
Polyglycholic Acid Suture 2-0 90cm
____________________________ Thoracic Catheter fr.28
Polyglycholic Acid Suture 2-0 Rapide Thoracic Catheter fr.30
Polyglycholic Acid Suture 3-0 Cutting Thoracic Catheter fr.32
Polyglycholic Acid Suture 3-0 Round Tracheostomy Tube #6.0
Polyglycholic Acid Suture 4-0 Cutting Tracheostomy Tube #7.0
_____________________________
Poole Drain Suction Set Tracheostomy Tube #7.5
Razor Tracheostomy Tube #8.0
Nurse on Duty (NameSilk 0 Round
& Signature) Under Pads- Blue Sheet
Silk 0 Multipack Under pads- Dri Sheet (Peach)
Silk 1 Multipack Urine Bag
Sill 2-0 Round Wound Drainage
Silk 2-0 Cutting Yankuer Suction Set
Silk 2-0 Multipack
Head Nurse/Supervisor
Silk 3-0 Round Alcohol 70%
Silk 3-0 Cutting Autoclave Tape
Silk 3-0 Multipack Battery 2A
Silk 4-0 Round Battery 3A
Silk 4-0 Cutting Battery Large
Silk 4-0 Multipack Battery Medium
Skin Stapler Decom. M. Mat
Sliptip Syringe Detergent Powder
Specimen Bottle Dispo Cap
Spinal Needle g.25 Distilled Water
Suction Catheter #8 I.E Gloves
Suction Catheter #10 KY Jellt Tube
Suction Catheter #12 Lysol
Suction Catheter #14 Pentel Pen
Suction Catheter #16 Plaster
Suction Catheter #18 Providone 10%
Surgical Blade #10 Providone 7.5 %
Surgical Blade #11 Record Book
Surgical Blade #12 Surgical Face Mask
Surgical Blade #15 Zonrox