OR SAMPLE CHARTING

EXCISION, SUBAREOLAR BREAST MASS

TIME > Into OR a __ year old female per
wheelchair/stretcher accompanied by NOD & orderly
with ongoing IVF of __________ @ __________cc level
infusing well at left arm.
>Conscious & coherent
>Informed Consent signed for Breast Mass Excision
>Assisted to OR table in supine position
>Cardiac Monitor attached w/ preop V/S
BP=_____________mmHg PR=_____________BPM
RR=_____________CPM
SPO2=___________%
>O2 inhalation administered @ 2 LPM per nasal
cannula
> Breast skin prepared done by NOD.
>Draped aseptically
TIME >Local Anesthesia infiltrated over breast mass
TIME >Operation started by Dr. _________________ wherein
small incision was done
>Incision deepened
TIME >Specimen out
>Drain placed
>Suturing of incision done by Dr. _________________
TIME >Operation finished
>Reapplication of betadine swab on sutured incision
and secured w/ top dressing
>Post op care done
>Post op V/S of BP= __________mmHg, PR=
__________BPM, RR= __________CPM, SPO2=___________%
TIME >Into recovery room per stretcher with same IVF of
__________ @ __________cc level.
Sarah

OR SAMPLE CHARTING
CAESAREAN SECTION
TIME > Into OR a __ year old __________ per
wheelchair/stretcher accompanied by NOD & orderly
with ongoing IVF of __________ @ __________cc level
infusing well at _____ arm.
>Conscious & coherent
>With consent signed for C.S.
>Ushered to OR table in supine position
> Cardiac Monitor attached w/ preop V/S
BP=_____________mmHg PR=_____________BPM
RR=_____________CPM
SPO2=___________%
> O2 inhalation administered @ 2 LPM per nasal
cannula
>Repositioned to side lying with knees flexed
>Lumbar skin prepped done by NOD.
>Draped aseptically
TIME >Operation started wherein a midline incision was
done by
Dr. _________________ assisted by Dr. _________________
>Incision deepened to peritoneum
>Amniotic sac artificially ruptured and fluid suctioned
>Uterus incised
>Fetal head was delivered
TIME >Delivered an alive baby _______ in cephalic
presentation via C.S.
>Double clamping of umbilical cord then cut
>Immediate NB care rendered by Pediatrician Dr.
_____________
TIME >Placenta out complete in Schultz presentation
followed with thorough evacuation of uterine blood
clots.
>Uterine incision sutured by layer
>Bilateral Tubal Ligation done
TIME >Left fallopian out

TIME >Right fallopian out

>Final count of sponges, needles and instruments
complete in the presence of the NOD
>Abdominal incision sutured layer by layer done by
surgical team
TIME >Operation finished
TIME >Above IVF consumed and changed with same _______
+ _______ u oxytocin
>Reapplication of betadine swab on sutured incision;
sutured with top dressing.
>Manual evacuation of blood clots
>Post-op care done
> Post op V/S of BP= __________mmHg, PR=
__________BPM, RR= __________CPM, SPO2=___________%
>Urine output of ____cc
TIME >To recovery room per stretcher with same ongoing
IVF of _______ + _______ u oxytocin @ _______cc level.
Sarah
OR CHARTING
TIME > Into OR a __ year old female per
wheelchair/stretcher accompanied by NOD & orderly
with ongoing IVF of __________ @ __________cc level
infusing well at left arm.
>Conscious & coherent
>Informed Consent signed for ___________________
>Ushered to OR table in supine position
> Cardiac Monitor attached w/ preop V/S
BP=_____________mmHg PR=_____________BPM
RR=_____________CPM
SPO2=___________%
> O2 inhalation administered @ 2 LPM per nasal
cannula
>Repositioned to side lying with knees flexed
>Lumbar skin prepped done by NOD
TIME >Spinal Anesthesia induced by Dr. _________________
>Back to supine position

>Abdominal skin prepped done by NOD

>Draped aseptically
TIME > Operation started wherein a _____________ incision
was done by
Dr. _________________ assisted by Dr. _________________
>Incision deepened to peritoneum
>Identification and isolation of diseased organ
TIME >Specimen out
>Hemostasis ensured
>Incision sutured layer by layer done by surgical team
TIME >Operation finished
>Reapplication of betadine swab on sutured incision
and secured w/ top dressing
>Post op care done
>Post op V/S of BP= __________mmHg, PR=
__________BPM, RR= __________CPM, SPO2=___________%
TIME >Into recovery room per stretcher with same IVF of
__________ @ __________cc level.
Sarah
Exploratory Laparotomy
TIME > Into OR a __ year old female per
wheelchair/stretcher accompanied by NOD & orderly
with ongoing IVF of __________ @ __________cc level
infusing well at left arm.
>Facial grimace noted
>Moans when in pain
>With NGT connected to drainage bottle
>With intact IFC
>Pale in appearance
>Informed Consent signed for Exploratory Laparotomy
>Ushered to OR table in supine position
> Cardiac Monitor attached w/ preop V/S
BP=_____________mmHg PR=_____________BPM
RR=_____________CPM
SPO2=___________%
TIME >PNSS 1L hooked at _____ arm
TIME >General Anesthesia inducted by Dr. _________________

TIME >Intubation done noted

>Abdominal skin prepped done by NOD
>Draped aseptically
>Draped aseptically
TIME > Operation started wherein a midline vertical incision
was done by
Dr. _________________ assisted by Dr. _________________
>Incision deepened until peritoneum
TIME >Above IVF of ___________ discontinued and changed
to packed RBC at ____arm
>Evacuation of hemoperitoneum
>Exploration and inspection of intra-abdominal cavity
>Liver packing done at site of liver injury with
subsequent application of gel foam
>Hemostasis ensured
TIME >Above IVF on the _____arm consumed and changed
to ____________

>Abdominal incision sutured layer by layer done by

surgical team
TIME >Operation finished
>Reapplication of betadine swab on sutured incision
and secured w/ top dressing
>Post op care done
>Post op V/S of BP= __________mmHg, PR=
__________BPM, RR= __________CPM, SPO2=___________%
TIME >20mg. Furosemide given by NOD via IV pushed
>Oropharyngeal suctioning done by Dr.
_________________ followed by extubation
TIME >Into recovery room per stretcher with same IVF of
__________ @ __________cc level.