EASTERN VISAYAS REGIONAL MEDICAL CENTER
Tacloban City, Philippines, 6500
[email protected] INSTRUMENT, SPONGE & NEEDLE COUNT SHEET
Date: _________________ Operating Room #: __________ Hospital No.: _____________
Name of Patient: _______________________________________ Age&Sex: ______________ Ward: ________________
Address: ______________________________________________ Date of Birth: ___________ Classification: _________
Surgeon: ___________________________________ Anesthesiologist: ____________________________
Assistant: __________________________________ Assistant: __________________________________
Assistant: __________________________________ Anesthesia Type: ______________ Surgery Type (Pls. Check)
Assistant: __________________________________ Time of Induction: _____________ Emergency
Time Started: _________ Elective
Time Ended: _________ Time Wheeled to OR: _________
Time Wheeled to PACU: _______
PRE-OPERATIVE DIAGNOSIS:
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POST-OPERATIVE DIAGNOSIS:
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OPERATION / PROCEDURE:
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SPONGES INSTRUMENTS (MS #____)
Abdominal Packs: __________ Curve: ________________
Square Packs: _____________ Straight: ______________
OS 4x8: __________________ Allis: _________________ Scrub Nurse: ___________________________
OS 4x4: __________________ Babcock: _____________ Reliever: ______________________________
OS 2x2: __________________ Scalpel: ______________ Reliever: ______________________________
Cherries: _________________ Tissue Forcep: _________ Reliever: ______________________________
Pinkish: __________________ Thumb Forcep: ________
Peanuts: _________________ Debakey: _____________
Nasal Pack: _______________ Mayo Scissors: _________ Circulating Nurse: _______________________
Nasal Strips: ______________ Metzenbaum: _________ Reliever: ______________________________
Cottonoids: _______________ Needle Holder: _________ Reliever: ______________________________
Cotton balls: ______________ Towel Clips: ___________ Reliever: ______________________________
Epi. ball: _________________ Schnidts: _____________
Mixters: ______________
Traumatic Needles: Army Navy: ____________ Remarks: _____________________________
Round: _____ Cutting: _____ Richardson: ____________ _____________________________
STRANDS: _______________ _____________________
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Atraumatic Needles: _____________________ _______________________________
_________________________ _____________________ SIGNATURE OVER PRINTED NAME
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_________________________ _____________________ ISNCS-OCN
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17-September-2018
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Rev. 00
