Charge

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:...