| Patient Name | Date | ||
|---|---|---|---|
| MRN/ID | Procedure | ||
| Surgeon | Scrub Nurse |
| Instrument Name | Count | Check | Notes |
|---|---|---|---|
| Scalpel Handle | |||
| Vascular Clamps (eg. Satinsky, DeBakey) | |||
| Pots Scissors | |||
| DeBakey Forceps | |||
| Bulldog Clamps | |||
| Vessel Dilators | |||
| Aneurysm Needle | |||
| Vascular Tunneler | |||
| Suction Tip | |||
| Other |
| Item | Count | Check | Notes |
|---|---|---|---|
| Sutures | |||
| Grafts | |||
| Drapes | |||
| Other |