Sample Charting for Nurses (during OR Case)

In from medicine ward via stretcher with IVF of D5W at 200cc level infusing well
regulated as fastdrip by AROD.
> conscious and coherent
> for Emergency Pericardiotomy with consent signed.
> Initial vital signs taken and recorded.
> placed on OR table with assistance.
> O2 inhalation via Nasal Cannula administered by AROD.
General Anaesthesia inducted by Dr. Sarmineto thru IV push.
> applied face mask
> OR sponges, instruments and needle prepared and completely counted by scrub nurse
and circulating nurse.
> skin preparation done aseptically
> drape done aseptically.
local anaesthesia given. (Lidocaine)
> OR started by Dr. Cruz and team.
Pericardial fluid drained thru straight catheter
> straight catheter applied connected to urine bag at OR site.
> above procedure done.
> suturing of open wound done layer by layer.
> Final counting of instruments, sponges and needles done completely and correctly.
OR ended.
> endoresed to PACU per stretcher.

Sign.

Sample Charting for Nurses (for Admission of Patient to Ward)

- In from Emergency Room via stretcher, unconscious and incoherent accompanied by
relative.
- Placed on bed on moderate high bed rest position.
- Admitted a 67 y/o male, married, with the chief complaint of loss of consciousness> prior to admission.
- with ongoing
IVF's of the ff:
- Main Line: Plain NSS 1L @ 900cc level regulated @ 25gtts/min
- Side Drip 1 : D5W 250cc + 1 ampule Dopamine @ 200cc level
- Side Drip 2 : D5W 250cc + 1 ampule Dobutamine @ 200 cc level regulated @
40gtts/min
- consent for admission signed by the relatives
- still with:
- endotracheal tube connected to ambu-bag to oxygen tanks @ 10LPM
- nasogastric tube closed and intact for feeding purpose
- foley catheter connected to urine bag draining into yellowish output potent and
intact
- still for the following labs:
- FBS, lipid profile, SGOPT, SGPT
- cranial CT scan once with funds, relative informed
- urinalysis
- manual ambubagging continuously done by the watcher
- suctioning done
- advised watcher to secure oral and IV meds
- closely watched and attended.

Sign.