INSTRUMENT COUNT SHEET

PT. NO……

ID TRAY C.S. SET CIRC

DATE ASSEMBLED SCRUB
BY:
QTY CATALOG VENDOR INSTRUMENT DESCRPTION SPD 1ST ADDED 2ND FINAL
NO. COUNT COUNT COUNT
2 REBSTOCK B.P. HANDLE NO.4
1 SCISSOR STRAIGHT (MAYO)
2 SCISSOR CURVE (MAYO)
2 TOOTH FORCEP
2 NON TOOTH FORCEP
4 KELLY CURVE (ARTERY)
8 ARTERY CURVE (MEDIUM)
4 KOCHER ST. FORCEP
3 NEEDLE HOLDER (MAYO)
4 ALLIS FORCEP
4 SPONGE HOLDER
1 DOYEN RETACTOR
2 RICHARDSON RETRACTOR
4 ARTERY ST.
4 GREEN ARMYTAGE
6 TOWEL CLIPS
1 BOWL
1 KIDNEY BASIN
SIG
55 TOTAL
GAUZE 10X 10 10
GAUZE 5X5 10

STERILIZER TYPE: STEAM DYNAMIC AIR REMOVAL (VACUM) CONTAINER SYSTEM

EXPOSURE TIME: 4 MIN AT 134 DEGREES CENTIGRADE
Please return the count sheet to CSSD
 INSTRUMENT COUNT SHEET

PT.NO……

ID TRAY MINOR SET CIRC

DATE ASSEMBLED SCRUB
BY:
QTY CATALOG VENDOR INSTRUMENT DESCRPTION SPD 1ST ADDED 2ND FINAL
NO. COUNT COUNT COUNT
1 REBSTOCK B.P. HANDLE NO.4
1 B.P. HANDLE NO.3
1 SCISSOR STRAIGHT
1 SCISSOR CURVE
2 TOOTH FORCEP
2 NON TOOTH FORCEP
4 ARTERY CURVE (MEDIUM)
4 MOSQUITO CURVE
2 NEEDLE HOLDER (MAYO)
2 ALLIS FORCEP
1 SPONGE HOLDER
2 LANGENBECK RETRACTOR
2 SEEN RETRACTOR
4 TOWEL CLIPS
1 BOWL
SIG
30 TOTAL
GAUZE 10X 10 10
GAUZE 5X5 10

STERILIZER TYPE: STEAM DYNAMIC AIR REMOVAL CONTAINER SYSTEM

EXPOSURE TIME: 4 MIN AT 134 DEGREES CENTIGRADE
Please return this count sheet to SPD
 INSTRUMENT COUNT SHEET

ID TRAY GENERAL SET CIRC

DATE ASSEMBLED SCRUB
BY:
QTY CATALOG VENDOR INSTRUMENT DESCRPTION SPD 1ST ADDED 2ND FINAL
NO. COUNT COUNT COUNT
1 REBSTOCK B.P. HANDLE NO.4
1 B.P. HANDLE NO.3
1 SCISSOR STRAIGHT
2 SCISSOR CURVE
2 TOOTH FORCEP
2 NON TOOTH FORCEP
1 ADSON FORCEP
1 SINGLEY-TUTTLE FORCEP
2 KELLY CURVE (ARTERY)
8 ARTERY CURVE (MEDIUM)
4 MOSQUITO CURVE
4 KOCHER ST. FORCEP
2 NEEDLE HOLDER
4 ALLIS FORCEP
2 SPONGE HOLDER
4 LANGENBECK RETRACTOR
4 BOBCOCK FORCEP
6 TOWEL CLIPS
1 BOWL
SIG
52 TOTAL
GAUZE 10X 10 10
GAUZE 5X5 10

STERILIZER TYPE: STEAM DYNAMIC AIR REMOVAL CONTAINER SYSTEM

EXPOSURE TIME: 4 MIN AT 134 DEGREES CENTIGRADE
 INSTRUMENT COUNT SHEET

ID TRAY LAPAROTOMY SET CIRC

DATE ASSEMBLED SCRUB
BY:
QTY CATALOG VENDOR INSTRUMENT DESCRPTION SPD 1ST ADDED 2ND FINAL
NO. COUNT COUNT COUNT
2 REBSTOCK B.P. HANDLE NO.4
1 B.P. HANDLE NO.3
1 SCISSOR STRAIGHT
2 SCISSOR CURVE
4 TOOTH FORCEP
4 NON TOOTH FORCEP
10 KELLY CURVE (ARTERY)
4 MOSQUITO CURVE
4 ARTERY ST.
6 ARTERY CURVE (MEDIUM)
4 KOCHER CURVE FORCEP
4 ATRAUMATIC FORCEP ST
4 ATRAUMATIC FORCEP CURVE
3 NEEDLE HOLDER
6 ALLIS FORCEP
4 SPONGE HOLDER
2 ARMY NAVY RETRACTOR
3 DEAVER RETRACTOR
1 RIBBON RETRACTOR
2 GEMINI FORCEP (right angle)
6 TOWEL CLIPS
1 POOLE SUCTION
1 BOWL
1 KIDNEY BASIN
80 SIG
TOTAL
GAUZE 10X 10 10
GAUZE 5X5 10

STERILIZER TYPE: STEAM DYNAMIC AIR REMOVAL CONTAINER SYSTEM

EXPOSURE TIME: 4 MIN AT 134 DEGREES CENTIGRADE
 INSTRUMENT COUNT SHEET

ID TRAY LAPAROSCOPY SET CIRC

DATE ASSEMBLED SCRUB
BY:
QTY CATALOG VENDOR INSTRUMENT DESCRPTION SPD 1ST ADDED 2ND FINAL
NO. COUNT COUNT COUNT
1 REBSTOCK B.P. HANDLE NO.4
1 B.P. HANDLE NO.3
1 SCISSOR STRAIGHT
1 SCISSOR CURVE
2 TOOTH FORCEP
2 NON TOOTH FORCEP
4 KELLY CURVE (ARTERY)
4 ARTERY CURVE (MEDIUM)
4 MOSQUITO CURVE
4 KOCHER CURVE FORCEP
2 NEEDLE HOLDER
4 ALLIS FORCEP
2 SPONGE HOLDER
2 MINI (LANGENBECK)RETRACTOR
1 SUCTION WITH STYLET
8 TOWEL CLIPS
2 BOWL
1 KIDNEY BASIN
SIG
42 TOTAL
GAUZE 10X 10 10
GAUZE 5X5 10

STERILIZER TYPE: STEAM DYNAMIC AIR REMOVAL CONTAINER SYSTEM

EXPOSURE TIME: 4 MIN AT 134 DEGREES CENTIGRADE

 INSTRUMENT COUNT SHEET

ID TRAY HEAMORRHOID SET CIRC

DATE ASSEMBLED SCRUB
BY:
QTY CATALOG VENDOR INSTRUMENT DESCRPTION SPD 1ST ADDED 2ND FINAL
NO. COUNT COUNT COUNT
1 REBSTOCK B.P. HANDLE NO.4
1 B.P. HANDLE NO.3
1 SCISSOR STRAIGHT
1 SCISSOR CURVE
1 TOOTH FORCEP
1 NON TOOTH FORCEP
4 ARTERY CURVE (MEDIUM)
2 KOCHER CURVE FORCEP
2 NEEDLE HOLDER
4 ALLIS FORCEP
1 SPONGE HOLDER
1 BOWL
4 TOWEL CLIPS
SIG
24 TOTAL
GAUZE 10X 10 10
GAUZE 5X5 10

STERILIZER TYPE: STEAM DYNAMIC AIR REMOVAL CONTAINER SYSTEM

EXPOSURE TIME: 4 MIN AT 134 DEGREES CENTIGRADE

 INSTRUMENT COUNT SHEET

ID TRAY D AND C SET CIRC

DATE ASSEMBLED SCRUB
BY:
QTY CATALOG VENDOR INSTRUMENT DESCRPTION SPD 1ST ADDED 2ND FINAL
NO. COUNT COUNT COUNT
1 REBSTOCK SIM SPECULUM (WEISSBARTH)
1 CURRETE DOUBLE ENDED
2 OVUM FORCEP
4 SPONGE HOLDER
1 VULSELLUEM FORCEP
1 BOWL
SIG
10 TOTAL
GAUZE 10X 10 20

STERILIZER TYPE: STEAM DYNAMIC AIR REMOVAL CONTAINER SYSYEM

EXPOSURE TIME: 4 MIN AT 134 DEGREES CENTIGRADE
 INSTRUMENT COUNT SHEET

ID TRAY CHOLECYSTECTOMY SET CIRC

DATE ASSEMBLED SCRUB
BY:
QTY CATALOG VENDOR INSTRUMENT DESCRPTION SPD 1ST ADDED 2ND FINAL
NO. COUNT COUNT COUNT
1 REBSTOCK B.P. HANDLE NO.4
1 B.P. HANDLE NO.3
1 SCISSOR STRAIGHT
2 SCISSOR CURVE
2 TOOTH FORCEP
2 NON TOOTH FORCEP
1 ADSON FORCEP
1 DEBAKEY FORCEP
4 KELLY CURVE (ARTERY)
4 MOSQUITO CURVE
4 ARTERY ST.
4 ARTERY CURVE (MEDIUM)
4 KOCHER CURVE/ST FORCEP
4 BOBCOCK FORCEP
2 MIXTER FORCEP (RIGHT ANGLE)
3 NEEDLE HOLDER
4 ALLIS FORCEP
4 SPONGE HOLDER
2 LANGENBECK RETRACTOR
3 DEAVER RETRACTOR
6 TOWEL CLIPS
1 YAUNKER SUCTION
2 BOWL
SIG
62 TOTAL
GAUZE 10X 10 10
GAUZE 5X5 5

STERILIZER TYPE: STEAM DYNAMIC AIR REMOVAL CONTAINER SYSTEM

EXPOSURE TIME: 4 MIN AT 134 DEGREES CENTIGRADE

 INSTRUMENT COUNT SHEET

ID TRAY TONSILLECTOMY SET CIRC

DATE ASSEMBLED SCRUB
BY:
QTY CATALOG VENDOR INSTRUMENT DESCRPTION SPD 1ST ADDED 2ND FINAL
NO. COUNT COUNT COUNT
1 REBSTOCK B.P. HANDLE NO.7
1 SCISSOR STRAIGHT
1 SCISSOR CURVE LONG
1 NEEDLE HOLDER
1 LUC FORCEP
1 TONSIL FORCEP
1 RHINOSCOPE MIRROR
1 TOOTH FORCEP
1 NON TOOTH FORCEP
3 ADENOID CURETTE
2 OVERHOLT (RIGHT ANGLE)
5 TOENNIS DISECTING FORCEP ST.
3 DRAFFIN STAND AND STICKS
2 DISECTOR
5 TONGUE DEPPRESOR (BLADES)
1 MOUTH GAG
6 TOWEL CLIPS
1 SUCTION TIP WITH STYLET
1 BOWL
1 KIDNEY BASIN
SIG
39 TOTAL
GAUZE 10X 10 10
GAUZE 5X5 5

STERILIZER TYPE: STEAM DYNAMIC AIR REMOVAL CONTAINER SYSTEM

EXPOSURE TIME: 4 MIN AT 134 DEGREES CENTIGRADE
PLS RETURN TO CSSD DATE STERILIZED
BATCH NO:
 INSTRUMENT COUNT SHEET

PT.NO_______

ID TRAY CIRCUMCISION SET CIRC

DATE ASSEMBLED SCRUB
BY:
QTY CATALOG VENDOR INSTRUMENT DESCRPTION SPD 1ST ADDED 2ND FINAL
NO. COUNT COUNT COUNT
1 REBSTOCK B.P. HANDLE NO 3
2 MOSQUITO CURVE
2 MOSQUITO ST.
1 NEEDLE HOLDER
1 TOOTH FORCEP
1 NON TOOTH FORCEP
1 BONE CUTTER
1 BOWL
1 SCISSOR
SIG
11 TOTAL
GAUZE 5 X 5 10

STERILIZER TYPE: STEAM DYNAMIC AIR REMOVAL CONTAINER SYSTEM

EXPOSURE TIME: 4 MIN AT 134 DEGREES CENTIGRADE
PLS RETURN TO CSSD DATE STERILIZED
BATCH NO:
 PT.NO_______

INSTRUMENT COUNT SHEET

ID TRAY DELIVERY SUTURE SET CIRC

DATE ASSEMBLED SCRUB
BY:
QTY CATALOG VENDOR INSTRUMENT SPD 1ST ADDED 2ND FINAL
NO. DESCRPTION COUNT COUNT COUNT
2 ARTERY ST
1 NON TOOTH FORCEP
1 NEEDLE HOLDER
1 SCISSOR
SIG
5 TOTAL

STERILIZER TYPE: STEAM DYNAMIC AIR REMOVAL CONTAINER SYSTEM

EXPOSURE TIME: 4 MIN AT 134 DEGREES CENTIGRADE
PLS RETURN TO CSSD DATE STERILIZED
BATCH NO:
 INSTRUMENT

DATE

OR SET
AND
DR

C.S.
MINOR
GENERAL
TOSILECTOMY
D AND C
CIRCUMSET
HEMORRHOID
SUTURE SET
THYROID
LAPAROTOMY SET
LAPAROSCOPY SET
INCISION AND DRAINAGE
LAPAROSCOPIC
 OTHER DEPARTMENT
DATE TIME
DEPARTMENT
QTY INSTRUMENTS DESCRIPTION Batch no. Date SIGNATURE
sterilized
 INSTRUMENTS COUNT SHEET

ID TRAY LAPAROSCOPIC SET CIRC

DATE ASSEMBLED SCRUB
BY:
QTY CATALOG VENDOR INSTRUMENT DESCRPTION SPD 1ST ADDED 2ND FINAL
NO. COUNT COUNT COUNT
2
1 NON TOOTH FORCEP
1 NEEDLE HOLDER
1 SCISSOR
SIG
5 TOTAL

STERILIZER TYPE: STEAM DYNAMIC AIR REMOVAL CONTAINER SYSTEM

EXPOSURE TIME: 20 MIN AT 121 DEGREES CENTIGRADE

 INSTRUMENT COUNT SHEET

ID TRAY THYROIDECTOMY SET CIRC

DATE ASSEMBLED SCRUB
BY:
QTY CATALOG VENDOR INSTRUMENT DESCRPTION SPD 1ST ADDED 2ND FINAL
NO. COUNT COUNT COUNT
1 REBSTOCK B.P. HANDLE NO.4
1 B.P. HANDLE NO.3
1 SCISSOR STRAIGHT
2 SCISSOR CURVE
2 TOOTH FORCEP
2 NON TOOTH FORCEP
1 ADSON FORCEP
16 MOSQUITO CURVE
4 ARTERY CURVE (MEDIUM)
4 KOCHER CURVE
3 NEEDLE HOLDER
4 ALLIS FORCEP
2 SPONGE HOLDER
4 WEITLANER RETRACTOR
2 LANGENBECK RETRACTOR
3 DEAVER RETRACTOR
6 TOWEL CLIPS
1 BOWL
SIG
59 TOTAL
GAUZE 10X 10 10
GAUZE 5X5 10
 STERILIZER TYPE: STEAM DYNAMIC AIR REMOVAL CONTAINER SYSTEM

EXPOSURE TIME: 4 MIN AT 134 DEGREES CENTIGRADE

INSTRUMENTS COUNT

ID TRAY I AND D SET CIRC

DATE ASSEMBLED SCRUB
BY:
QTY CATALOG VENDOR INSTRUMENT DESCRPTION SPD 1ST ADDED 2ND FINAL
NO. COUNT COUNT COUNT
1 REBSTOCK B.P. HANDLE NO.3
1 B.P. HANDLE NO.4
2 ARTERY CURVE
2 ALLIS FORCEP
1 NEEDLE HOLDER
1 TOOTH FORCEP
1 NON TOOTH FORCEP
1 SPONGE HOLDER
1 SCISSOR CURVE
1 SCISSOR ST.
1 BOWL
SIG
13 TOTAL
GAUZE 5 X 5 5
GAUZE 10 X 10 10

STERILIZER TYPE: STEAM DYNAMIC AIR REMOVAL CONTAINER SYSTEM

EXPOSURE TIME: 4 MIN AT 134 DEGREES CENTIGRADE