Case No.

: Name of student: Year and Section:

OR Preference Card Name of Patient: Date of Admission: Time Started Bed #: Hospital #: Surgeon: Anesthesiologist: Scrub Nurse: Circulating Nurse: Age: Sex: Civil Status:

Date of Surgery: Time ended: Admission #: Registration/Reciept #: Assistant Surgeon:

Chief Complaint:

Rationale/Pathophysiology basis in relation to its diagnosis:

Post- Operative Diagnosis: Rationale/Definition:

Complete Surgical Procedure: Definition:

Type of anesthesia: Specific Technique: Anesthetic Agent: Mechanism of Action: Position: Incision: Skin Preparation: Draping:

Sutures and Needles: Tissue Layer

Suture Used

Needle

Suturing Technique

Instruments Used: Cutting

Grasping

Retracting

Clamping

Others