Perpetual Succor Hospital & Maternity
OR
OPERATION RECORD
Patient
Doctor
Date
Case No.
Pre-operative diagnosis
Pre-operative diagnosis
Operative diagnosis
Operative diagnosis
Operation
Surgeon
Assistants
Anesthesia
Anesthetic
Amount
Anesthetist
Pro-operative medication
Post-operative orders
Post-operative orders
Time started
Time finished
Remarks
Remarks
Remarks
Nurse
Nurse In-Charge Signature *
Upload a PNG file with transparent background, or draw your signature below
OR
Clear
Download PNG
Please provide a signature.
Technic of operation
Specimen
Disposition
Gross description
Biopsy report
Attending Physician/Assistant
Attending Physician/Assistant Signature *
Upload a PNG file with transparent background, or draw your signature below
OR
Clear
Download PNG
Please provide a signature.
Save as a form template
IMPORTANT REMINDERS
PLEASE CHECK THE APPROPRIATE BOXES.
All information required in this form are necessary. Claim forms with incomplete information shall not be processed.
FALSE/INCORRECT INFORMATION OR MISREPRESENTATION SHALL BE SUBJECT TO CRIMINAL, CIVIL OR ADMINISTRATIVE LIABILITIES