Name of Patient :

Address:
MAJOR CIRCULATING CASE SLIP Age:
Case No.:
Pre-op Diagnosis:
NAME OF STUDENT:
STUDENT NUMBER: Post -op Diagnosis:

Operation Performed:

Time Started:__________
Surgeon:
Assistant:
CLINICAL COORDINATOR: Anesthesiologist:
PRC NO.: VALID UNTIL: _____________ Type of Anesthesia:
PNA NO.:__________________VALID UNTIL: _____________ Medicine Used:
ANSAP NO.:_______________VALID UNTIL:_____________ Anesthesia Started:
Instrument Nurse:
Sponge Nurse:
Staff Nurse on Duty:
Nurse Instructor:
Agency:
Name of Patient : Name of Patient :
Address: Address:
Age: Sex:____________ Age:
Case No.: Ward:__________ Date:_____________Case No.:
Pre-op Diagnosis: Pre-op Diagnosis:

Post -op Diagnosis: Post -op Diagnosis:

Operation Performed: Operation Performed:

Time Started:__________ Time Finished:______________Time Started:__________

Surgeon: Surgeon:
Assistant: Assistant:
Anesthesiologist: Anesthesiologist:
Type of Anesthesia: Type of Anesthesia:
Medicine Used: Medicine Used:
Anesthesia Started: Anesthesia Started:
Instrument Nurse: Instrument Nurse:
Sponge Nurse: Sponge Nurse:
Staff Nurse on Duty: PRC No.: Staff Nurse on Duty:
Nurse Instructor: PRC No.: Nurse Instructor:
Agency: Agency:

Name of Patient :
 Address:
MAJOR SCRUB CASE SLIP Age:
Case No.:
Pre-op Diagnosis:
NAME OF STUDENT:
STUDENT NUMBER: Post -op Diagnosis:

Operation Performed:

Time Started:__________
Surgeon:
Assistant:
CLINICAL COORDINATOR: Anesthesiologist:
PRC NO.: VALID UNTIL: _____________ Type of Anesthesia:
PNA NO.:__________________VALID UNTIL: _____________ Medicine Used:
ANSAP NO.:_______________VALID UNTIL:_____________ Anesthesia Started:
Instrument Nurse:
Sponge Nurse:
Staff Nurse on Duty:
Nurse Instructor:
Agency:
Name of Patient : Name of Patient :
Address: Address:
Age: Sex: Age:
Case No.: Ward:__________ Date:_____________Case No.:
Pre-op Diagnosis: Pre-op Diagnosis:

Post -op Diagnosis: Post -op Diagnosis:

Operation Performed: Operation Performed:

Time Started:__________ Time Finished:______________Time Started:__________

Surgeon: Surgeon:
Assistant: Assistant:
Anesthesiologist: Anesthesiologist:
Type of Anesthesia: Type of Anesthesia:
Medicine Used: Medicine Used:
Anesthesia Started: Anesthesia Started:
Instrument Nurse: Instrument Nurse:
Sponge Nurse: Sponge Nurse:
Staff Nurse on Duty: PRC No.: Staff Nurse on Duty:
Nurse Instructor: PRC No.: Nurse Instructor:
Agency: Agency:
 Name of Patient :
Address:
Sex:____________ Age: Sex:____________
Ward:__________ Date:_____________Case No.: Ward:__________ Date:_________
Pre-op Diagnosis:

Post -op Diagnosis:

n Performed: Operation Performed:

ted:__________ Time Finished:______________Time Started:__________ Time Finished:__________

Surgeon:
Assistant:
Anesthesiologist:
Type of Anesthesia:
Medicine Used:
Anesthesia Started:
Instrument Nurse:
Sponge Nurse:
PRC No.: Staff Nurse on Duty: PRC No.:
PRC No.: Nurse Instructor: PRC No.:
Agency:
Name of Patient :
Address:
Sex:___________ Age: Sex:____________
Ward:__________ Date:_____________Case No.: Ward:__________ Date:_______
Pre-op Diagnosis:

Post -op Diagnosis:

n Performed: Operation Performed:

ted:__________ Time Finished:______________Time Started:__________ Time Finished:_________

Surgeon:
Assistant:
Anesthesiologist:
Type of Anesthesia:
Medicine Used:
Anesthesia Started:
Instrument Nurse:
Sponge Nurse:
PRC No.: Staff Nurse on Duty: PRC No.:
PRC No.: Nurse Instructor: PRC No.:
Agency:

Name of Patient :
 Address:
Sex:___________ Age: Sex:
Ward:__________ Date:_____________Case No.: Ward:__________ Date:_______
Pre-op Diagnosis:

Post -op Diagnosis:

n Performed: Operation Performed:

ted:__________ Time Finished:______________Time Started:__________ Time Finished:__________

Surgeon:
Assistant:
Anesthesiologist:
Type of Anesthesia:
Medicine Used:
Anesthesia Started:
Instrument Nurse:
Sponge Nurse:
PRC No.: Staff Nurse on Duty: PRC No.:
PRC No.: Nurse Instructor: PRC No.:
Agency:
Name of Patient :
Address:
Sex: Age: Sex:
Ward:__________ Date:_____________Case No.: Ward:__________ Date:________
Pre-op Diagnosis:

Post -op Diagnosis:

n Performed: Operation Performed:

ted:__________ Time Finished:______________Time Started:__________ Time Finished:__________

Surgeon:
Assistant:
Anesthesiologist:
Type of Anesthesia:
Medicine Used:
Anesthesia Started:
Instrument Nurse:
Sponge Nurse:
PRC No.: Staff Nurse on Duty: PRC No.:
PRC No.: Nurse Instructor: PRC No.:
Agency: