COLLEGE OF NURSING
OPERATION RECORD (CIRCULATING)
Name of Patient: _____________________________________________________________________________________
Age: _____________ Sex: _____________ Status: _____________ Ward/Room: ________________
Case No.: ______________________________ RVU: _________________________
Name of Hospital: ___________________________________________________
PRE-OPERATIVE DIAGNOSIS: _____________________________________________________________________
_____________________________________________________________________
POST-OPERATIVE DIAGNOSIS:_____________________________________________________________________
_____________________________________________________________________
Name of Surgeon: _____________________________________________________________________
Name of Anesthesiologist: _____________________________________________________________________
Type of Anesthesia: __________________________________________________
Time Anesthesia Inducted/Intubated: ______________(AM/PM)
Time Anesthesia Ended/Extubated: ______________(AM/PM)
Time Operation Started: __________(AM/PM)
Time Operation Ended: __________(AM/PM)
OPERATION PERFORMED: ___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
Date of Operation: _______________________
Name and Signature of Student: ______________________________________________________________
Date Signed: __________________________________
Name and Signature of Clinical Instructor: ______________________________________________________
Date Signed: _________________________________
Name and Signature of Circulating Nurse on Duty: _____________________________________________
Date Signed: _________________________________
Name and Signature of Operating Room Supervisor: ___________________________________________
Date Signed: _________________________________
Document Number Effectivity Date Revision Number
LDCU-FORMS-CON-023 August 7, 2023 000
COLLEGE OF NURSING
OPERATION RECORD (SCRUB)
Name of Patient: _____________________________________________________________________________________
Age: _____________ Sex: _____________ Status: _____________ Ward/Room: ________________
Case No.: ______________________________ RVU: _________________________
Name of Hospital: ___________________________________________________
PRE-OPERATIVE DIAGNOSIS: _____________________________________________________________________
_____________________________________________________________________
POST-OPERATIVE DIAGNOSIS:_____________________________________________________________________
_____________________________________________________________________
Name of Surgeon: _____________________________________________________________________
Name of Anesthesiologist: _____________________________________________________________________
Type of Anesthesia: __________________________________________________
Time Anesthesia Inducted/Intubated: ______________(AM/PM)
Time Anesthesia Ended/Extubated: ______________(AM/PM)
Time Operation Started: __________(AM/PM)
Time Operation Ended: __________(AM/PM)
OPERATION PERFORMED: ___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
Date of Operation: _______________________
Name and Signature of Student: ______________________________________________________________
Date Signed: __________________________________
Name and Signature of Clinical Instructor: ______________________________________________________
Date Signed: _________________________________
Name and Signature of Scrub Nurse on Duty: _____________________________________________
Date Signed: _________________________________
Name and Signature of Operating Room Supervisor: ___________________________________________
Date Signed: _________________________________
Document Number Effectivity Date Revision Number
LDCU-FORMS-CON-022 August 7, 2023 000
Liceo de Cagayan University
Paseo del Rio Campus, Macasandig
Cagayan de Oro City
College of Nursing
SUMMARY OF PERFORMNCE EVALUATION ACHIEVING
INTRA-OPERATIVE CARE COMPETENCY
In accordance with PRC Board of Nursing Memorandum No. 01 Series of 2009
Signature over Printed Names of Learner:_________________________________________
INTRA-OPERATIVE CARE DESIRED 1st 2nd 3rd AVERAGE
COMPETENCIES RATING Case Case Case RATING
I. SAFE AND QUALITY NURSING CARE (SCQ)
1. Utilizes nursing process in the care of
OR Client
a. Obtains comprehensive client’s
4
information by checking complete
accomplishment of the pre-operative
checklist/client’s chart.
b. Identifies priority needs of the client at
4
the Operating Room.
c. Provides needed nursing interventions
4
based on identified needs.
d. Monitor’s client’s response to surgery. 2
2. Promotes safety and comfort of clients
2
inside the O.R.
3. Performs the function of the Scrub
Nurse: 4
a. Performs surgical scrub correctly.
b. Wears sterile gown and gloves
2
aseptically.
c. Prepares surgical instruments, sponges,
sutures, and other supplies in functional 2
arrangement.
d. Hands instruments, sponges, sutures, and
other needed materials according to 2
surgeon’s preferences
e. Performs surgical count accurately. 2
4. Performs the function of the
Circulating Nurse: 2
a. Anticipates the needs of the surgical team.
b. Sets up the O.R. and the needed
2
equipment.
c. Receives client for surgery/endorses
2
client post-operatively.
d. Assists in skin preparation and draping of
2
client.
5. Administers medications and other
2
health therapeutics safely.
II. MANAGEMENT OF RESOURCES, ENVIRONMENT AND EQUIPMENT (MRE)
1. Organizes workload to facilitate timely
4
client care.
2. Utilizes adequate and appropriate
2
resources to support the O.R. Team.
3. Ensures functionality of O.R. resources. 2
4. Maintains a safe environment at the O.R.
2
by observing the principles of asepsis.
III. HEALTH EDUCATION (HE)
1. Implement appropriate Health Education
Activities to client based on needs 2
assessment.
IV. LEGAL RESPONSIBILITIES (LR)
1. Adheres to Legal and Institutional
2
Protocols regarding informed consent.
V. ETHICO-MORAL RESPONSIBILITIES (EMR)
1. Respects the right of the O.R. client. 2
2. Accepts responsibility and accountability
for own decisions and actions as an O.R. 2
Nurse
VI. PERSONAL AND PROFESSIONAL DEVELOPMENT (PPD)
1. Performs O.R. function according to
4
Professional Standards.
2. Possesses positive attitude towards
learning Surgical and O.R. related 2
knowledge and skills.
VII. QUALITY IMPROVEMENT (QI)
1. Participates in quality improvement 2
activities related to infection control and
successful O.R. Operations.
2. Identifies and reports variances in sterility 2
and other O.R. activities.
VIII. RESEARCH (R)
1. Disseminate results of the O.R. related
research findings to clinical group and
2
other members of the O.R. Team as
appropriate.
IX. RECORDS MANAGEMENT (RM)
1. Maintain accurate and updated 2
documentation of client care.
X. COMMUNICATION (Comm)
1. Establishes rapport with clients, 1
significant others and members of the
health team.
2. Uses appropriate information mechanisms 2
to facilitate communication inside the
O.R. and with other departments in the
hospital.
XI. COLLABOFRATION AND TEAMWORK (CTM)
1. Collaborates plan of care with other 2
members of the health team.
TOTAL SCORE 75
Certified True and Correct: ________________________________________
(Signature over Printed Name)
____________________________________ ____________________________________
Clinical Instructor Clinical Coordinator
License Number: ______________________ License Number:______________________
PRC Card No./Validity Date:_____________ PRC Card No./Validity Date: ____________
____________________________________
DEAN ______________________________
License Number:______________________ Academic Year Graduated
PRC Card No./Validity Date: ____________
