General Hospital • Operating Theatre

Sponges, Sharps & Instruments Count Form

F-OT-04

Patient Name

MRN

Surgery Date

Procedure

Items	First Count	Additional Quantity	Mark (✓) if count is correct
Items	First Count	Additional Quantity	Second Count	Third Count	Closing Count
RAYTEC 45X45
RAYTEC 40X40
RAYTEC 30X30
RAYTEC 10X20
RAYTEC 4X4
CHERRIES
PEANUTS
PATTIES
COTTON PELLETS / ROLLS
BLADES
NEEDLES
INSTRUMENT SET:


BILATERAL / ADDITIONAL KITS
RAYTEC 45X45
RAYTEC 40X40
RAYTEC 30X30
RAYTEC 10X20
RAYTEC 4X4
CHERRIES
PEANUTS
PATTIES
BLADES
NEEDLES
INSTRUMENT SET:

Final Count Results:

Completed (Correct) Not Completed (Incorrect)

Surgeon Notified

Action taken in case of count discrepancy:

Surgeon

Scrub Nurse

Circulating Nurse