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Operating Room Write-Up: College of Nursing

This document is an operating room write-up template used by nursing students to document details of surgical procedures they observe, including patient information, pre-operative diagnosis and chief complaint, surgery performed, medical staff involved, anesthesia used, history of present illness, discussion of problem and operation, instruments used, postoperative diagnosis, complications, and patient's condition at the end of the operation.

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Dizah Faye Osboro
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822 views1 page

Operating Room Write-Up: College of Nursing

This document is an operating room write-up template used by nursing students to document details of surgical procedures they observe, including patient information, pre-operative diagnosis and chief complaint, surgery performed, medical staff involved, anesthesia used, history of present illness, discussion of problem and operation, instruments used, postoperative diagnosis, complications, and patient's condition at the end of the operation.

Uploaded by

Dizah Faye Osboro
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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COLLEGE OF NURSING

OPERATING ROOM Write-Up

Name of Student: Section&Group: Dates of Exposure:


Name of Patient: Date of Admission:
Hospital: Ward:
Age: Sex: Civil Status: Religion:
Preoperative Diagnosis:
Chief Complaint:

Operation Performed:
Surgeon:
Instrument Nurse: Sponge Nurse:
Anesthesiologist: Type of Anesthesia:
History of Present Illness:

Pathology/Explanation of the Problem:

Brief Discussion of Proposed Operation:

Instruments: Uses/ Functions (Place at the back of this sheet)

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