Submitted by: Submitted by vincevil
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Category: Other Topics
Date Submitted: 08/07/2012 03:13 PM
The Health Centrum Inc. __ Pay __ Emergency
Banica, Roxas City, Capiz __ Service
OR/DR/PACU Department
Charge Slip
Patient’s Name: ______________________________________________________Room/Ward: _______ Date and Time: ________________
Operation: _________________________________________________________________ Anesthesia: ______________________________
Surgeon: __________________________ Anesthesiologist: ____________________________ Other Service: __________________________
Machines
__ Anesthesia Machine
__ Anesthesia Ventilator
__ Cautery Machine
__ Patient Monitor
__ Infusion Pump
__ Suction Machine
__ Syringe Pump
__Capnograph
__ Cardiac Monitor
__ Colpo Machine
__ Drop Light
__ Pulse Oximeter
Others: ___________________
___________________
Anesthesia Method
__ Intraspinal
__ Epidural
__ O2
__ GA
__ TIVA
__ N2O
Anesthesia Supplies
___ O2 Cannula (Adult/Pedia)
___ O2 MasK (Adult/Pedia)
___ ET Tube
___ Nasotracheal tube
___ Laryngeal mask Airway
___ Airway (Oral/Nasal)
___ Epidural Set
Others: ___________________________
SOLUTIONS
___ NSS irrigation
___ 10% Formalin
___ Hyrdogen Peroxide
___ Methyline Blue
___ Povidone Soap
___ Povidone Paint
___ Sterile Water
Sutures
_________________
_________________
_________________
_________________
_________________
_________________
_________________
_________________
Sponges
___ OS Ordinary
___ 4x4 Raytex
___ 4x8 Raytex
___ Abdo Pads
___ Square Pads
___ AP Strip
___ Cherries
___ Peanuts
___ Nasal Packing
___ Vaselinized
Syringes
___ 1 cc
___ 3 cc
___ 5 cc
___ 10 cc
___20 cc
___ 30 cc
___ Asepto Syringe
Others: _____________
Circulating Nurse: __________________________________________
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Pharmacy Charge Slip
Patient’s Name:...