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    Sample Charting or

    Uploaded by

    Katherine Ibarra
    A patient received an IV of D5W at 1L infusing well with an indwelling foley catheter and output of 50cc light colored urine. She underwent a pre-op consent check and was safely transferred to the OR table where spinal prep and anesthesia induction occurred. A C-section was performed, delivering a live baby girl followed by the placenta. The IV was changed, instruments and sponges were counted and found complete, and the incision was sutured and dressed before the patient was transferred to the ward.

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    Sample Charting or

    Uploaded by

    Katherine Ibarra
    2K views1 page
    A patient received an IV of D5W at 1L infusing well with an indwelling foley catheter and output of 50cc light colored urine. She underwent a pre-op consent check and was safely transferred to the OR table where spinal prep and anesthesia induction occurred. A C-section was performed, delivering a live baby girl followed by the placenta. The IV was changed, instruments and sponges were counted and found complete, and the incision was sutured and dressed before the patient was transferred to the ward.

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    SAMPLE CHARTING OR (1)

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    A patient received an IV of D5W at 1L infusing well with an indwelling foley catheter and output of 50cc light colored urine. She underwent a pre-op consent check and was safely transferred to the OR table where spinal prep and anesthesia induction occurred. A C-section was performed, delivering a live baby girl followed by the placenta. The IV was changed, instruments and sponges were counted and found complete, and the incision was sutured and dressed before the patient was transferred to the ward.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    2K views1 page

    Sample Charting or

    Uploaded by

    Katherine Ibarra
    A patient received an IV of D5W at 1L infusing well with an indwelling foley catheter and output of 50cc light colored urine. She underwent a pre-op consent check and was safely transferred to the OR table where spinal prep and anesthesia induction occurred. A C-section was performed, delivering a live baby girl followed by the placenta. The IV was changed, instruments and sponges were counted and found complete, and the incision was sutured and dressed before the patient was transferred to the ward.

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    SAMPLE CHARTING (OR)

    Date Special Endorsement Nurse’s Notes

    Feb. 24, 2011 7-3


    -received from DR with an IVF of
    D5W 1L @ 800 cc level infusing well.
    -with an indwelling foley catheter
    attached to urine bag with an
    output of 50 cc light colored urine
    -pre-op consent checked
    -transferred to OR table safely
    -spinal prep done aseptically
    9:50 am -induction of anesthesia by DR.
    Nelson Gamboa
    -skin prep done
    -counting of instruments, needles
    and sponges done
    -proper draping done
    10:07 am -LSCS by Dr. Reynaldo Alipio
    assisted by Mrs. Elvira Morales
    10:10 am -delivered an alive baby girl
    10:12 am -delivered placenta
    -above IVF changed to D5LRS +
    20 “u” Sintocinon
    -counting of instruments, sponges
    and needles done/complete
    -suturing layer by layer by
    surgeon
    -pressure dressing over incision
    site
    -IE done by Dr. Alipio
    -to ward
    ____________________________________________________________ name and signature______

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