PREFERENCE CARD ________ CASE # Name of Student: Mary Marjorie F.

Rodavia Year / Section & RLE Group: III- 8 RLE 4 Name of Patient: Date of Admission: Bed No.: Surgeon: Anesthesiologist: Scrub Nurse: Chief Complaint: Rationale: Post-Operative Diagnosis: Rationale: Complete Surgical Procedure: Definition: Indication: General Type of Anesthesia: Specific Technique: Skin Preparation/Assistance Done: Items Used to Administer Anesthesia: Age: Sex: Date of Surgery: Hospital No.: Civil Status: Time Started/Ended:

Assistant Surgeon: Circulating Nurse:

Main Anesthetic Agent: Mechanism of Action: Other Medications Used: Mechanism of Action: Position: Equipment/s Used for Positioning: Incision: Skin Preparation: Draping: Surgical Safety Checklist: SIGN IN: Before Induction of Anesthesia Is the patients identity, site, procedure and consent CONFIRMED? Is the surgical site marked? Is the anesthesia machine and medication cart checked? Is the pulse oximeter attached and working? Equipment needed available and checked (microscope/lap towel/H-L Yes No N/A

machine, etc.) Does the patient has any: Known allergy? Difficult airway/aspiration risk? Risk of BLOOD loss? Has the Surgical Site Infection (SSI) bundle been undertaken? Antibiotic prophylaxis within 60 min. Patient warming (Temp checked) Hair removal/shave site Glycemic control Has venous thromboembolism prophylaxis been undertaken? Is essential imaging displaying? Is the initial count done and recorded?

TIME OUT:

Before Skin Incision Before Start of Procedure Confirm if all team members introduced themselves and their roles? ____Yes ____No Patients identity and procedure to be done and site of operation confirmed by Surgeon/Anesthesiologist/Nurse ____Yes ____No To Surgeon: Any anticipated critical events? __________________________________________________ __________________________________________________ To Anesthesiologist: Any patient specific concerns? __________________________________________________ __________________________________________________ To Scrub Nurse: Any instrument/suture concerns? __________________________________________________ __________________________________________________ To Perfusion/Technician: Any equipment issues? __________________________________________________ __________________________________________________

SIGN OUT:

Before Skin Closure or Before End of Procedure Nurse verbally confirms: -the name of the procedure to be recorded -if instruments, sponges, sharps, and needles counts are complete: _____Yes _____No Has the specimen been labeled correctly (Including patients name)? _____Yes _____No Specimen __________________________________________ ___________________________________________________ Pathologist_________________________________________ Any equipment problems identified? ___________________________________________________ ___________________________________________________ Surgeon/Anesthesiologist/Nurse concerns: Any key concerns for transfer to recovery? Any patient management issues? ___________________________________________________ ___________________________________________________ ___________________________________________________