COUNTING SHEET

I. PURPOSE
This form is use to properly count instruments, sharps, needles, and sponges before, during , and
after the procedure.

II. DEFINITION OF TERMS

To properly and correctly count instruments, sharps (including sutures and needles) and sponges,
regardless size and type.

III. PROCESS FLOW

A. CIRCULATING NURSE

I. Initiate the surgical count and participate in it.

II. Visualize the items on the sterile field as they’re being counted.
III. Ensure that the count is visible to the room.
IV. Start each case with a clean white board/count sheet.
V. Remove any leftover, countable items from a previous case, before beginning a new one.
VI. Keep track of any items that are dropped on the floor.
VII. If a suture, lap, raytec, etc., drops on the floor, don’t throw it away! Make note of it and set it
safely aside so it can be accounted for during final counts.
VIII. Document the surgical count
IX. If there’s an incorrect count, communicate and document per protocol

B. SCRUB NURSE

I. Participate in the count!

II. Don’t leave it up to the circulating nurse to look at the back table and make sure everything
is accounted for!
III. Have an organized sterile field.
IV. Keeping the sterile field well organized makes it easier to find items.
V. Always know the location of soft goods and instruments within the sterile field.
VI. Alert the circulating nurse any time an item is placed inside the patient (packing in the
throat, lap inside a wound, etc) so it can be documented.
VII. Verify all items are intact when they are returned to the back table.
VIII. Examine suture to make sure they’re not broken, for example.
IX. Always count items in such a way that the circulating nurse can visualize what is being
counted.

OPERATING SCHEDULE FORM

I. PURPOSE
This form is use to notify operating/delivery room department for any elective surgeries.

II. DEFINITION OF TERMS

Operating room schedule form is use to notify operating/delivery room department to be ready for
upcoming procedures and prepare necessary equipment, instruments, and manpower needed
before surgery.

III. PROCESS FLOW

A. Fill up the necessary details including personal details, type of operation and anesthesia, mode
of payment and other details needed.
 B. Once completed inform OR/DR department for sending the forms with them
C. Each department must have a copy of the form and attach to the patient chart.

MAJOR/ MINOR OPERATING ROOM CHARGES

I. PURPOSE
This form is use to charge necessary equipment, supplies and other charges used in the
procedure.

II. DEFINITION OF TERMS

The form serve as base for charging necessary items and supplies used in operating
room/delivery room.

III. PROCESS FLOW

A. The Incharge nurse must identify the procedure if it is a Major and Minor Case.
B. Fill out the necessary form including patient information (Name, Age, Sex, Date, Room/bed
No., And Type of surgical procedure).
C. The Nurse must charge from time to time before, during and after the procedure to avoid
omitting negligence.
D. The nurse must fill up the quantity use in the procedure such as medicines, supplies, sutures,
and equipments.
E. Once the procedure is done you may charge the supplies and items in Hospital Information
System (HIS) (please see policy for charging on HIS)
F. Attach the charge form in patient chart accordingly.

WHO SURGICAL CHECKLIST

I. PURPOSE
It is one affordable and sustainable tool for reducing deaths from surgery in low and middle
income countries.

II. DEFINITION OF TERMS

The checklist serves to remind the surgical team of important items to be
performed before and after the surgical procedure in order to reduce adverse events such
as surgical site infections or retained instruments.

III. PROCESS FLOW

A. A Circulating Nurse should take the lead in completing the document.

B. The WHO Surgical Safety Checklist is divided into three sections, to be completed at three
separate times during the operative period:

C. Sign In – To be completed before the induction of anaesthesia, in the presence of the
anaesthetist and will answer the ff:
I. Has the patient confirmed his/her identity, site, procedure, and consent?
II. Is the site marked?
III. Is the anaesthesia machine and medication check complete?
IV. Is the anaesthesia machine and medication check complete?
Does the patient have a known drug allergy?
V. Does the patient have a difficult airway or aspiration risk?
VI. Does the patient have a risk of >500 mL blood loss?
D. Time Out – To be completed before the first incision, acting as the final opportunity to identify
the patient, the procedure, and the site involved
 I. Confirm all team members have introduced themselves by name and role
II. Confirm the patient's name, procedure, and where the incision will be made
III. Has antibiotic prophylaxis been given within the last 60 minutes?
IV.Anticipated critical events for the surgeon:
What are the critical or non-routine steps?
How long will the case take?
What is the anticipated blood loss?
V.Anticipated critical events for the anesthetist:
Are there any patient-specific concerns?
VI.Anticipated critical events for the nursing team:
Has sterility (including indicator results) been confirmed?
Are there equipment issues or any concerns?
VII. Is essential imaging displayed?
E. Sign Out – To be completed prior to the key members of the operating team leaving the
operating room

I. Nurse verbally confirms:

The name of the procedure
Completion of instrument, sponge and needle counts
Specimen labelling (read specimen labels aloud, including patient name)
Whether there are any equipment problems to be addressed

II. To surgeon, anaesthetist and nurse:

What are the key concerns for recovery and management of this patient?

F. Must be sign by the surgeon, anesthesiologist, scrub nurse and circulating nurse after the
procedure.
G. Once completed it will attach to the patient charts along with other operating room forms.

INFORMED CONSENT FOR OPERATION, ANESTHESIA AND OTHER

PROCEDURE
I.PURPOSE:
This policy applies to all patients to receive proper information and acknowledge the procedure,
risks, benefits, alternative treatment, explained by competent medical practitioners.

II.DEFINITION:
Informed Consent is the process in which a health care provider educates a patient about the
risks, benefits and alternative of a given procedure or intervention and the patient must be
competent to make a voluntary decision about whether to undergo the procedure. It is an ethical
and legal obligation of a medical practitioner to provide proper information.

III.PROCESS FLOW
A. Patient has to receive proper information of the following:
i. Procedure, anesthesia and its implications
ii  Patient’s diagnosis and prognosis
iii Options for treatment including non-operative care and no treatment
iv The likelihood of success
v The risks inherent in the procedure 
vi Side effects and complications
vii The consequences of non-operative alternatives
viii Potential follow-up treatment
B. Obtain a patient's consent prior to surgery and ensure that the patient has sufficient time and
information to make an informed decision

i.  must be signed by patient of legal age, for minor age, parents or guardian is responsible
to obtain consent
ii. Exceptions to Informed Consent
iii Patient is incapacitated
iv Life-threatening emergencies with inadequate time to obtain consent
 v. Voluntary waived consent
 vi Patient with psychological and psychiatric problem

C.Document the following:

i  Nature of the procedure
ii  Risks and benefits of the procedure
iii Reasonable alternatives 
iv Risks and benefits of alternatives
v. Name of Physician and  Anesthesiologist

D. Witness must signed the Informed consent (members of the healthcare team involved)

POST ANESTHESIA DISCHARGE CRITERIA (MODIFIED ALDRETE SCORING)

I.PURPOSE: To determine when post- operative patients can be safely discharged from the post
anesthesia care.

II.DEFINITION: 
ALDRETE SCORING is a measurement  of recovery after anesthesia that includes gauging a
patient’s consciousness, movement, respiration, circulation, and oxygen saturation

III.PROCESS FLOW

A. The Nurse in PACU must do the following assessment and care procedure 
i.  Assessment must be complete and documented
ii. Vital signs should be taken every 5 minutes for 15 minutes; every 15 minutes for 30
minutes and every 30 minutes until patient discharge from PACU
iii. Medications
    1.3.1 First dose of IV antibiotic medications are initiated. 
    1.3.2 Analgesia and antiemetics may be administered IV/IM as prescribed by
anesthesiologist
    1.3.3 Assess and reassess pain after pain reliever initiated: 30 minutes following IV
administration; 1 hour after IM route of medication administration.
iv. Ensures that the correct IV fluid is infused according to the physician’s order.
v. Turn patient from side to side every 2 hours unless contraindicated by the surgeon.
vi. Patient may be discharged from PACU when evidence that the spinal block is receding
at least 2 dermatomes and a minimum level of T10.
B. Patient meets Modified Aldrete Score of >9 or more
  i. Respirations
                  (2) Breaths, cough freely
(1).Dyspnea
(0) Apnea

              ii. O2 Saturation
(2) O2 saturation >92% on room
                (1) Air supplemental Oxygen
        (0) O2 saturation <92% on 02

              iii. Circulation (BP)

                (2) BP ± 20 mmHg pre-op value          
                (1) BP ± 20-50 mmHg pre-op
                (0) BP ± 50 mmHg pre-op     

   iv. Level of Consciousness 

                (2) Awake and oriented  
                (1) Response to stimulus
                (0) Not responding

              v. Movement
                (2) Moves 4 limbs
                (1) Moves 2 limbs
                (0) moves 0 limbs
 C. Inform the patient and the family that the patient will be transferred to another unit.

 D. PACU Nurse notifies the appropriate department that the patient is ready for transfer to
prepare the room

   i.  If oxygen therapy is to be continued, the patient is transferred to the receiving unit with
oxygen
   ii The patient is transported with the same level of monitoring that is expected to be
provided on the receiving unit
   iii. ICU patients who require special procedure must be accompanied by the nurse until
they are returned to ICU

E. Document and endorse the patient properly to the receiving unit.

     
VOLUNTARY CONSENT FOR STERILIZATION

I.DEFINITION: This is a consent form agreed upon by a couple authorizing the Obstetrician and
health team to proceed with sterilization as a means of family planning.

II.PURPOSE: To ensure that both parties agreed for sterilization as a method of family planning.

III. PROCESS FLOW:

A. Confirm the Physician’s order

B. Identify the patient correctly
C.Ensure that the OB Physician had counseled the couple and both are aware of the benefits and
possible risk of the procedure

D.Ask the couple to sign the consent for sterilization form and take note that the following details
has been furnished

i.  Name and signature of patient

ii.  Name and signature of spouse
iii. Date and Time signed
iv. Name and signature of Physician
v.  Name and signature of witness 

E.Attach to the patient's chart for documentation and endorse properly.

OPERATIVE RECORD

I.Definition: Operative Record is a legal document which contains accurate records of anesthesia,
surgery, and post operative care.

II.Purpose: To ensure that there is sufficient information about the procedure in the record
immediately after surgery or other high risk procedure to manage the patient throughout the post
procedure period.

III.PROCESS FLOW:

A. Identify the patient correctly, make sure consent has been obtained

B. Prepare patient for the procedure

C. Surgeons must complete th operative record right after the procedure and sign above his/her
full name, it should have complete details:
i. Patient’s name
ii. Primary surgeon/physician and assistants
iii. Pre-operative diagnosis
iv Post-operative diagnosis
vii Procedure performed
vi Findings of the procedure
vii Specimen removed
viii Estimated blood loss
ix Date and time of the procedure (started and ended)
x Indications of the procedure
xi Intra-operative complications
xii Full description of the procedure

D. OR Nurse (Circulating Nurse) make sure that the record is completed by the surgeon.
E. Operative Record must be keep on patient’s chart and be endorsed properly.