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.