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SURGICAL SLIP SURGICAL SLIP

Name of Student:___________________________________ Name of Student:___________________________________


Date :________________Time Started: ________ Date :________________Time Started: ________
Case Number :________________ Case Number :________________
Hospital :___________________________________ Hospital :___________________________________
___________________________________ ___________________________________
Surgical procedure performed: Surgical procedure performed:
____________________________________ ____________________________________
____________________________________ ____________________________________
____________________________________ ___________________________________
_
Classification of Operation: Minor Major
Classification of Operation: Minor Major
Type of Experience: Scrub Nurse Circulating Nurse
Type of Experience: Scrub Nurse Circulating Nurse
O.R. Nurse: ___________________________________
(Name & Signature) O.R. Nurse: ___________________________________
(Name & Signature)
Clinical Instructor:_________________________________
(Name & Signature) Clinical Instructor:_________________________________
Forms Control #: SLU-SON-Slips 001 (Name & Signature)
Forms Control #: SLU-SON-Slips 001

NURSERY SLIP DELIVERY SLIP


Name of Student:___________________________________ Name of Student:___________________________________

Date :_____________Time of Delivery: _______ Date :_____________Time of Delivery: _______


Case Number :________________ Case Number :________________
Hospital :___________________________________ Hospital :___________________________________
___________________________________ ___________________________________
Immediate newborn care Performed: Diagnosis: ____________________________________

DR Nursery OR ____________________________________
Type of Delivery: NSD CS Forceps
Type of Delivery: NSD CS Forceps

Nurse on Duty: ___________________________________


(Name & Signature) Nurse on Duty: ___________________________________
(Name & Signature)
Clinical Instructor:_________________________________
(Name & Signature) Clinical Instructor:_________________________________
(Name & Signature)
Forms Control #: SLU-SON-Slips 002 Forms Control #: SLU-SON-Slips 003

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