Form Surgical Safety Checklist

 

IDJIMENYV MJABA@A@ XJBOJFADA@ / X_CYJFZ_ FNAK@CYVNM / N@\AYNL

 _YZF Oa`yuasn` 

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  Gj`ns cpjrasn

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  FXGX

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  FXGX A`jstjsn

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YNK@ N@ (Yjojeub N`fumsn A`jstjsn) Va`kkae ........... ...................... ........... Xumue ................. [NO 

Apamad ecmasn cpjrasn fnta`fan7 fnta`fan7 □ ^a 

□ Vnfam 

  @aba Xasnj` 7 ..................................... .................................................................... ...............................   Vke Eadnr

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  @c. _B

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VNBJ CZV (Yjojeub N`snsn Muent/Xrcsjfur Fnak`cstm/N`vasnl) Va`kkae ........... ...................... ........... Xumue ................. ................. [NO  Mc`lnrbasn sjbua a`kkcta tnb u`tum bjbpjrmj`aema` `aba fa` pjra``ya77 pjra``ya □A`jstjsn □Cpjratcr □Asnstj` cpjratcr □Xjrawat n`strubj` □Xjrawat snrmuejr

Apamad pasnj` tjead fnmc`lnrbasn7 fnmc`lnrbasn7 □Nfj`tntas`ya □Ecmasn cpjrasn □Xrcsjfur cpjrasn □Xjrsjtugua` cpjrasn/n`lcrbjf ic`sj`t  

□Vnfam fnpjreuma`

Apamad tjead fneamuma` pjbjrnmsaa` pjrsnapa` fa` mjej`kmapa`77 mjej`kmapa` □ Bjsn` a`jstjsn  □ Coat a`jstjsn   Apamad puesj cxybjtjr tjrpasa`k pafa pasnj` fa` ojrlu`ksn77 ojrlu`ksn □ ^a  □ Vnfam 

_B 8:>

OA_ICFJ

  Fnak`csns

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YNK@ CZV (Yjojeub Euma Cpjrasn Fntutup) Va`kkae ...................... ...................... Xumue ................. ................. [NO Mc`lnrbasn sjiara ensa` pjrawat 7 pjrawat 7 □Apamad `aba prcsjfur tn`fama` sufad fntuens □Mjej`kmapa` pjraeata` n`strubj` sjsuan faltar fa`  gubead □Gubead pj`kku`aa` massa □Gubead pj`kku`aa` garub □Xjeaojea` spjsnbj` (`aba fa` rjknstjr) □Apamad afa aeat-aeat atau basaead ean` ya`k darus fnsjejsanma`

Mc`lnrbasn7 Mc`lnrbasn7 □@aba pasnj` □Ecmasn cpjrasn □Xrcsjfur cpjrasn Apamad fnpjreuma` pj`kku`aa` a`tnonctnma prclneamsns7 prclneamsns7 □ ^a  □ Vnfam 

Z`tum tnb ojfad (aden ojfad, aden a`jstjsn fa` pjrawat)77 pjrawat) □Apa pjrtnboa`ka` mdusus pafa basa pjbuenda` fa` ba`agjbj` pasnj`3

A`tnsnpasn mjgafna` mrntns7 mrntns7 Z`tum aden ojfad □Apamad afa a`tnsnpasn tjrdafap mjgafna` tnfam fndarapma` sjeaba

Apamad pasnj` bjbnenmn rnwayat aejrkn7 aejrkn7 □ ^a  □ Vnfam  Mjsuenta` gaea` `apas/ rnsnmc aspnrasn7 aspnrasn7 □ ^a, fa` pjraeata` tjrsjfna   □ Vnfam  _nsnmc mjdnea`ka` farad ≪:88 ii (; ii/mkOO pafa a`am)3 a`am) 3 □ Vnfam  □ ^a, fa` ? amsjs N\/ sj`trae fa` ianra` fnrj`ia`ama` Apamad aeat nbpea`tasn tjrsjfna7 □ ^a  □ Vnfam 

cpjrasn, sjpjrtn mjdnea`ka` farad3 Z`tum aden a`jstjsn □Apamad afa pjrdatna` mdusus tjrdafap mc`fnsn pasnj` ya`k spjsnlnm3 (asba, pj`yamnt ya`k bjbpjrojrat gaea``ya cpjrasn) Z`tum tnb pjrawat □Apamad sufad stjrne (bjenputn dasne n`fnmatcr) tjead fnmc`lnrbasn3 □Apamad afa basaead pjraeata`/ojojrapa mjmdawatnra`3 Apamad rc`tkj` pj`tn`k fntabpnema`3 □ ^a  □ Vnfam 

Xjrawat snrmuejr

Xj`ata a`jstjsn

Xjrawat snrmuejr

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Vnb Ojfad

@aba

Va`fa ta`ka`

Cpjratcr

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Fcmtjr A`jstjsn

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Xjrawat snrmuejr

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