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SPUS Counting Form

This document is an operating room counting form used to track items used during a surgical procedure. It lists various sponges, instruments, needles and other materials used and provides columns to track the initial count, items added, and total counts in the beginning, middle and end of the procedure. The form requires signatures from scrub nurses/technicians and circulating nurses to verify that counting of items was done correctly and completely, and to document any items intentionally retained.

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Illidian Stormrage
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89 views2 pages

SPUS Counting Form

This document is an operating room counting form used to track items used during a surgical procedure. It lists various sponges, instruments, needles and other materials used and provides columns to track the initial count, items added, and total counts in the beginning, middle and end of the procedure. The form requires signatures from scrub nurses/technicians and circulating nurses to verify that counting of items was done correctly and completely, and to document any items intentionally retained.

Uploaded by

Illidian Stormrage
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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OPERTING ROOM

COUNTING FORM

DATE:

LAST NAME: FIRST NAME: MIDDLE NAME:

SURGEON/S: ANESTHESIOLOGIST/S:

PROCEDURE:

INITIA ADDE TOTA


FIRST TOTA SECOND TOTA THIRD TOTA
L D L
COUN + COUNT L COUNT L COUNT L
T FIEL FLOO FIELD FLOOR FIELD FLOOR
SPONGES D R

4X8 OS WITH
4X8 OS WITHOUT
VISCERAL PACK
SQUARE PACK
AP PACK
PEANUTS
CHERRY BALLS
4X4 OS
COTTONOIDS
TONSIL BALLS
LAP OS
OTHER
INSTRUMENTS
TOWEL CLIPS
MOSQUITO CURVED
MOSQUITO
STRAIGHT
ALLIS
BABCOCK
KOCKERS
NEEDLE HOLDER
MIXTERS
THUMB AND TISSUE
BLADE HOLDER
ARMY NAVY
RICHARDSON
DEAVER
MALLEABLE
RAKE
SCREWS
SUCTION TIP
STYLET
OVUM
OTHERS:

THIRD TOTA
COUNT L
FIELD FLOOR
INITIA
L
ADDE
D
TOTA
L
FIRST TOTA SECOND TOTA
COUN + COUNT L COUNT L Counting of Sponges,
T FIEL FLOO FIELD FLOOR
SHARPS D R Instruments, Needles
AUTROMATIC and other items used
(ATR) were conscientiously
LOOSE NEEDLES
done with correct and
BLADES
complete finding
SCISSORS
Specific item was
CAUTERY TIP
intentionally retained by
OTHER
the surgical team due to following
reason/s:_________________________________
________________________________________________________________________________________________________

_______________________ _______________________
SCRUB NURSE/ OR TECH 1 CIRCULATING NURSE 1
NAME AND SIGNATURE NAME AND SIGNATURE

_______________________ _______________________
SCRUB NURSE/ OR TECH 2 CIRCULATING NURSE 2
NAME AND SIGNATURE NAME AND SIGNATURE

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