indicator of Instruments concern:

Complete Incomplete

Shave skin in OR:

Yes No

By Clipper
By Blade

Surgical skin Scrub in OR:

Yes No

Betadine scrub
Chlorhexidine scrub 4%

Surgical skin Paint in OR:

Yes No

Betadine solution
2% Chlorhexidine in alcohol
0.5% Chlorhexidine
Alcohol 70%

Use wound protector / drape:

Yes No

Urinary catheterization in OR:

Yes No

retained cathe number Fr.
Intermittent cath cc
Problem

inserted in OR by:

Name

per id:
password: