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Surgical Count Sheet Template

This document appears to be a surgical instrument and sponge count sheet used during a medical procedure. It contains fields to record patient information, diagnosis details, medical staff involved, and a list of instruments and items used along with spaces for nurses to sign after counting to confirm all items were present before and after the procedure.

Uploaded by

erwin kurniawan
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© All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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126 views2 pages

Surgical Count Sheet Template

This document appears to be a surgical instrument and sponge count sheet used during a medical procedure. It contains fields to record patient information, diagnosis details, medical staff involved, and a list of instruments and items used along with spaces for nurses to sign after counting to confirm all items were present before and after the procedure.

Uploaded by

erwin kurniawan
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

SURGICAL COUNT INSTRUMENT, NEEDLES & SPONGES

Nama :________________________________________________________
Med. Rec. No :______________________ Usia :___________________
Jenis Kelamin :P/L Tanggal :___________________
Pre Operation Diagnosis :_________________________________________________
Operation Done :_________________________________________________
Post Operation Diagnosis :_________________________________________________
Surgeon :_____________________ Asist. Surgeon :___________________
Anesthesiologist :_____________________ Anesthesia Nurse:__________________
Scrub Nurse :_____________________ Circulating Nurse :__________________

Ovum Forceps Kidney Basin

Vulselum Bowl

Hegars Dilators Gauze 10x10

Double Speculum Prep. Balls

Double Ended Curettes

Big Curette

Uterine Sound

Instrument Used : D & C Set

Scrub Nurse :________________ Circulating Nurse :_____________


SURGICAL COUNT INSTRUMENT, NEEDLES & SPONGES

Nama :________________________________________________________
Med. Rec. No :______________________ Usia :___________________
Jenis Kelamin :P/L Tanggal :___________________
Pre Operation Diagnosis :_________________________________________________
Operation Done :_________________________________________________
Post Operation Diagnosis :_________________________________________________
Surgeon :_____________________ Asist. Surgeon :___________________
Anesthesiologist :_____________________ Anesthesia Nurse:__________________
Scrub Nurse :_____________________ Circulating Nurse :__________________

Ovum Forceps Tooth Forceps

Allis Forceps Non tooth Forceps

Babcock Kidney Basin

Right angle Gallipots

Straight Kockers Towel Clip

Straight Artery Forceps Langenback retractor

Curved Artery Forceps Morris Retractor

Straight Mosquito Forceps Deaver

Curved Mosquito Sinn Retractor

Bowel Forceps Gauze 10x10

Metal Suction Pedia Pack 20x20

Big Blade Holder Abdominal Pack 40x40

Small Blade Holder Peanut

Needle Holder Cherries

Tissue Scissor Needles

Suture Scissor Prep. Balls

Instrument Used : ________________________________________________

Scrub Nurse :________________ Circulating Nurse :_____________

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