General Hospital • Operating Theatre

Implant Traceability & Stickers Log

F-OT-16

Patient Name

MRN

Date of Surgery

Primary Surgeon

Procedure Performed

Pre-Insertion Verification (Circulating & Scrub)

Sterility confirmed (CSSD release / indicators checked) Packaging integrity and Expiry Date checked Correct implant side/site confirmed with surgeon Patient consent includes implant authorization

Device & Component Log

Affix original manufacturer labels in the dashed boxes. If no label is available, manually record Lot/Serial and UDI.

Component 01

Affix Original Label
(Barcode / UDI) Here

Component Name / Type

Size / Side

Lot / Serial No.

Expiry Date

Component 02

Affix Original Label
(Barcode / UDI) Here

Component Name / Type

Size / Side

Lot / Serial No.

Expiry Date

Component 03

Affix Original Label
(Barcode / UDI) Here

Component Name / Type

Size / Side

Lot / Serial No.

Expiry Date

Component 04

Affix Original Label
(Barcode / UDI) Here

Component Name / Type

Size / Side

Lot / Serial No.

Expiry Date

Component 05

Affix Original Label
(Barcode / UDI) Here

Component Name / Type

Size / Side

Lot / Serial No.

Expiry Date

Component 06

Affix Original Label
(Barcode / UDI) Here

Component Name / Type

Size / Side

Lot / Serial No.

Expiry Date

Vendor / Company Name

Loaner Tray Reference #

VERIFICATION: I confirm that all devices implanted during this procedure are accurately recorded above, all original stickers are affixed, and the records match the items used on the sterile field. This record must be filed in the patient's medical record.

Primary Surgeon

Name / ID

Signature

Scrub Nurse / Tech

Name / ID

Signature

Circulating Nurse

Name / ID

Signature