Operating Room Charting 5cpl

40

7 am

8

45

8

9:17

10:20

10:47

11:10

Received from Rm. 321 after proper identification. Conscious and coherent. c IVF of D5LR 1Lx125cc/h c 220cc more to infuse. c complete pre-op checklist For open reduction internal fixation-IM nailing static Interlocking L femur, c consent signed by himself. Transferred to OR stretcher, wheeled in to OR 3. Transferred and secured to OR table. Attached to cardiac monitor and pulse oximeter c O2 saturation of 100% Attached to O2 @ 2 lpm via nasal prong Vital signs closely monitored by ACCI Lopez. Prepared for induction of anesthesia. Placed in L lateral decubitus position. Epidural anesthesia inducted by Dr. Mabunay. Desired anesthesia effect noted. Initial count of sponges, needles,and instruments done. Old and soiled dressing and elastic bandage removed. Foley catheter inserted aseptically and attached to urobag c dark amber output noted. Ortho prep done aseptically. Draped aseptically. Procedure started by Dr. Soriaso, assisted by Dr. Anayan and Dr. Caballero c CCI Cruz. Bleeders clamped , ligated and cauterized as encountered. Fracture exposed and reduced. Edges curetted. Peroxide wash done. Intramedullary nail inserted @ L femur Intra-op xray done. Film seen by Dr. Soriaso. Screws applied. JP drain applied. Debridement: ORIF: IM nailing done. Final count of sponges, needles and instruments done, Completed and relayed to surgeon. Skin closed c staple wires. Dressing and elastic bandage applied. Procedure ended. Transferred to stretcher; kept clean and dry. Chilling noted, blanket and light provided. BT of WB blood type O Rh “+” 500 cc, c SN# 114503 started and regulated.

12:20

Brought to PACU, awake, c IVF of PLR 1L @ 850cc, infusing well. c same BT ongoing. c FC in place. o Latest VS: T=37.6 C, P=89 beats/min, R=22 breaths/min, BP=120/80mmHg. Endorsed to NOD.