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Get DA 5179-1 1987-2024

INTRAOPERATIVE DOCUMENT MEDICAL RECORD For use of this form see AR 40-66 the proponent agency is the office of The Surgeon General. 1. PATIENT TRANSPORTED TO OPERATING ROOM VIA BY 3. DATE TIME PATIENT ARRIVED IN SUITE 2. PATIENT IDENTIFIED RECORD REVIEWED AND PROCEDURE VERIFIED BY 4. PATIENT IN ROOM TIME NUMBER 5. PREOPERATIVE EMOTIONAL STATUS CALM ANXIOUS EXCITED CRYING ANGRY WITHDRAWN OTHER Specify COMMENTS 6. NURSING PERSONNEL ASSIGNED SCRUB RELIEF CIRCULATOR 7. POSITION AND POSITIONAL AIDS Specify SUPINE LITHOTOMY PRONE KRASKE LATERAL LEFT SIDE UP RIGHT SIDE UP 8. SKIN PREPARATION HAIR REMOVAL DONE BY METHOD NO YES OR DEPILATORY CLIP NURSING UNIT RAZOR PREP SOLUTION Specify SITE BY WHOM 9. LOCATION OF EXTERNAL DEVICES LEGEND X Ground Pad 10. COUNTS -- Safety Strap C Correct Other Tourniquet I Incorrect First Closing Count Final Closing Sponge Yes No Needle Sharp Instrument Name - Last first middle Grade Date Hospital or Medical Facility 12. ELECTROSURGERY DEVICE S ESU ESU NO GROUND PAD BRAND LOT NO BIPOLAR NO DA FORM 5179-1 OCT 87 REPLACES DA FORM 5179-1 TEST DEC 82 WHICH IS OBSOLETE* USAPA V1. 01 13. PROSTHESIS IMPLANTS IF YES NAME ID NUMBER MANUFACTURER MEDICATIONS/ORDERS IRRIGATION/MEDICATIONS GIVEN IN OPERATING ROOM NOT BY ANESTHESIA DOSAGE WOUND IRRIGATION PREPARED BY GIVEN BY NO TYPE S OTHER ORDERS CARRIED OUT BY PHYSICIAN S SIGNATURE 15. X-RAY IN OPERATING SPECIMEN S FROZEN SECTION FS CULTURE C NAME ROOM TYPE/SIZE IF YES SITE LABORATORY SPECIMENS 18. DRESSING/IMMOBILIZATION Specify TUBES DRAINS/PACKING 19. ADDITIONAL INFORMATION 20. OPERATION S PERFORMED 22. PATIENT TRANSPORTED TO OPERATING ROOM VIA BY 3. DATE TIME PATIENT ARRIVED IN SUITE 2. PATIENT IDENTIFIED RECORD REVIEWED AND PROCEDURE VERIFIED BY 4. PATIENT IN ROOM TIME NUMBER 5. PREOPERATIVE EMOTIONAL STATUS CALM ANXIOUS EXCITED CRYING ANGRY WITHDRAWN OTHER Specify COMMENTS 6. PATIENT IN ROOM TIME NUMBER 5. PREOPERATIVE EMOTIONAL STATUS CALM ANXIOUS EXCITED CRYING ANGRY WITHDRAWN OTHER Specify COMMENTS 6. NURSING PERSONNEL ASSIGNED SCRUB RELIEF CIRCULATOR 7. POSITION AND POSITIONAL AIDS Specify SUPINE LITHOTOMY PRONE KRASKE LATERAL LEFT SIDE UP RIGHT SIDE UP 8. NURSING PERSONNEL ASSIGNED SCRUB RELIEF CIRCULATOR 7. POSITION AND POSITIONAL AIDS Specify SUPINE LITHOTOMY PRONE KRASKE LATERAL LEFT SIDE UP RIGHT SIDE UP 8. SKIN PREPARATION HAIR REMOVAL DONE BY METHOD NO YES OR DEPILATORY CLIP NURSING UNIT RAZOR PREP SOLUTION Specify SITE BY WHOM 9. SKIN PREPARATION HAIR REMOVAL DONE BY METHOD NO YES OR DEPILATORY CLIP NURSING UNIT RAZOR PREP SOLUTION Specify SITE BY WHOM 9. LOCATION OF EXTERNAL DEVICES LEGEND X Ground Pad 10. COUNTS -- Safety Strap C Correct Other Tourniquet I Incorrect First Closing Count Final Closing Sponge Yes No Needle Sharp Instrument Name - Last first middle Grade Date Hospital or Medical Facility 12. LOCATION OF EXTERNAL DEVICES LEGEND X Ground Pad 10. COUNTS -- Safety Strap C Correct Other Tourniquet I Incorrect First Closing Count Final Closing Sponge Yes No Needle Sharp Instrument Name - Last first middle Grade Date Hospital or Medical Facility 12. ELECTROSURGERY DEVICE S ESU ESU NO GROUND PAD BRAND LOT NO BIPOLAR NO DA FORM 5179-1 OCT 87 REPLACES DA FORM 5179-1 TEST DEC 82 WHICH IS OBSOLETE* USAPA V1. .

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