Checklist Surgical Instrument Set

Name Of Set : Laparatomy Set

CSSD Qty Checker
NO ITEMS CODE Std OT CSSD
1 Mayo Safety BF493R 3
2 Scalpel Handle No. 4 BB084R 1
3 Scalpel Handle No. 7 BB077R 1
4 Scalpel Handle No. 3 BB075R 1
5 Tissue Forceps BD577R 1
6 Cushing Del STR Forceps BD238R 1
7 De'Bakey Atr Forceps FB414R 1
8 De'Bakey Atr Forceps FB415R 1
9 De'Bakey Atr Forceps FB416R 1
10 Yankauer Suction Cannule GF944R 1
11 Foerster Sponge Forceps BF122R 5
12 Edna Towel Clamp BF461R 5
13 TC Metz w/1 Scisscors BC271W 1
14 TC Metz w/1 Scisscors BC257W 1
15 TC Metz w/1 Scisscors BC277W 1
16 Mayo Scissors BC547R 1
17 TC Mayo Scissors BC253R 1
18 Deaver Scissors BC374R 1
19 Halsted-Mosquito Forceps BH111R 3
20 Crile Forceps BH145R 4
21 Colley Artery Forceps MD469 8
22 Kocher-Ochsner Forceps BH644R 2
23 Artery Forceps Crafoord BH227R 2
24 Crafoord Delicate Forceps BH225R 2
25 Allies Forceps EA016R 2
26 Gemini Clamp BJ104R 1
27 Gemini Clamp BJ102R 1
28 Mixter Forceps Long BJ061R 1
29 Tc Mayo-Hegar Nidle Holder BM066R 1
30 Tc Mayo-Hegar Nidle Holder BM067R 1
31 Tc Hegar-Mayo Nidle Holder BM068R 1
 32 Tc Hegar-Mayo Nidle Holder BM070R 1
33 Langenbeck retractor BT325R 2
34 leriche Abdominal Spatula BT730R 1
35 Leriche Spatula BT732R 1
36 Laboratory Dish JG521R 1
37 Laboratory Dish JG523R 1
38 Kidney Tray JG504R 1
39 Kidney Tray JG506R 1
40
41
42
CSSD Pcs OT
Date Packet : Date Used :
Checked by : Theatre :
Discripancies 1st 2nd
Scrub Nurse
Circulating Nurse
Discripancies
Remarks
OT
 Checklist Surgical Instrument Set

Name Of Set : MINI SET

Qty Checker
NO ITEMS CODE CSSD
Std OT
1 Mayo Safety BF493R 1
2 Scalpel Handle No. 3 BB073R 1
3 MC'Indoe Del Thumb Forceps BD236R 1
4 Gillies Tissue Forceps BD660R 1
5 Standart Tissue Forceps BD557R 1
6 Tc Baby-Metz Scissors BC259R 1
7 Surgical Scissors BC324R 1
8 Halsted-Mosquito forceps BH111R 2
9 Baby Crile Forceps BH141R 4
10 Needle Holder BM015R 1
11 Needle Holder BM016R 1
12 Sponge holder BF112R 1
13 Edna Towel Clamp BF461R 4
14 Allis Forceps EA015R 2
15 Ragnell DB. Wound Hook BT004R 2
16 Langenbeck-Mannerfelt BT946R 2
17 Laboratory Dish JG521R 1
18 Kidney Tray JG504R 2
19 TC Mayo - Lexer BC 284 R 1
20 Army Retractor BT 041 R 2
21 Laboratory Dish JG 522 R 1
22 Curette No Code 1
CSSD Pcs OT
Date Packet : Date Used :
Checked by : Theatre :
Discripancies 1st
Scrub Nurse
Circulating Nurse
Discripancies
Set

Checker
Remarks
CSSD

OT

2nd
 Checklist Surgical Instrument Set

Name Of Set : MINOR SET

Qty Checker
NO ITEMS CODE CSSD
Std OT CSSD
1 Mayo Safety BF493R 1
2 Scalpel Handle No. 3 BB073R 1
3 MC'Indoe Del Thumb Forceps BD236R 1
4 Gillies Tissue Forceps BD660R 1
5 Standart Tissue Forceps BD557R 1
6 Tc Baby-Metz Scissors BC259R 1
7 Surgical Scissors BC324R 1
8 Halsted-Mosquito forceps BH111R 2
9 Baby Crile Forceps BH141R 4
10 Needle Holder BM015R 1
11 Needle Holder BM016R 1
12 Sponge holder BF112R 1
13 Edna Towel Clamp BF461R 4
14 Allis Forceps EA015R 2
15 Ragnell DB. Wound Hook BT004R 2
16 Langenbeck-Mannerfelt BT946R 2
17 Laboratory Dish JG521R 1
18 Kidney Tray JG504R 2
19 TC Mayo - Lexer BC 284 R 1
20 Army Retractor BT 041 R 2
21 Laboratory Dish JG 522 R 1
22 De'Bakey Atr Forceps FB414R 1
23 De'Bakey Atr Forceps FB415R 1
24 Foerster Sponge Forceps BF122R 1
25 Mayo Scissors No Code 1
26
27
CSSD Pcs OT
Date Packet : Date Used :
Checked by : Theatre :
Discripancies 1st 2nd
Scrub Nurse
Circulating Nurse
Discripancies
t

Remarks

OT
 Checklist Surgical Instrument Set

Name Of Set : Orthopaedic Small

CSSD Qty Checker
NO ITEMS CODE Std OT CSSD Remarks
1 Mayo Safety BF493R 2
2 Scalpel Handle No. 3 BB073R 1
3 Scalpel Handle No. 7 BB077R 1
4 Tissue Forseps BD549R 1
5 Gillies Dissect. Forseps BD557R 1
6 Gillies Tissue Forseps BD660R 1
7 Mayo Scissor STR BC547R 1
8 Surgical Scissors STR BC325R 1
9 TC Matzenbaum Scissors BC263R 1
10 Foerster Sponge FCPS BF122R 2
11 Edna Towel Clamp BF461R 12
12 Rochester-Pean Forceps BH445R 2
13 Kocher - Ochsner Forseps BH644R 2
14 TC Mayo - Hegar NDL Holder BM065R 1
15 TC Mayo - Hegar NDL Holder BM066R 1
16 Volkmann Bone Curette FK631R 1
17 Kocher Retractor 1 - Prong BT238R 1
18 Kocher-Langenbeck BT354R 2
19 Us - Army Retrac BT041R 2
20 Lane Trethowan Bone Lever FK135R 1
21 Bristow Bone Lever FK140R 1
22 Langenbeck Elevator FK139R 1
23 Mac Donald Elevator FK291R 1
24 Bone Elevator FK171R 1
25 Elvatrhrprs-Hdlcvdrnd-Tip FK321R 1
26 Beyer Bone Rongeur FO514R 1
27 Fergusson Suct. Cann GF373R 1
28 Fergusson Suct. Cann GF374R 1
29 Laboratory Dish 0.063 L JG521R 1
30 Laboratory Dish 0.16 L JG522R 1
31 Laboratory Dish 0.4 L JG523R 1
32 Kidney Tray JG504R 1
33 Kidney Tray Stainless JG506R 1
34
35
36
CSSD Pcs OT
Date Packet : Date Used :
Checked by : Theatre :
Discripancies 1st 2nd
Scrub Nurse
Circulating Nurse
Discripancies
 Checklist Surgical Instrument Set

Name Of Set : Orthopaedic Large

CSSD Qty Checker
NO ITEMS CODE Std OT CSSD Remarks
1 Mayo Safety BF493R 2
2 Scalpel Handle No. 4 BB084R 1
3 Scalpel Handle No. 3 BB073R 1
4 Scalpel Handle No. 7 English BB077R 1
5 Tissue Forseps BD549R 1
6 Standard Tissue Forseps BD561R 1
7 Gillies Tissue Forseps BD660R 2
8 Steel Ruler AA805R 1
9 TC Matzenbaum Scissors BC263R 1
10 Surgical Scissors STR BC325R 1
11 TC Metz Sciss Broad-Bld BC287R 1
12 TC Mayo-Hegar NDL Holder BM065R 1
13 TC Hegar Needle Holder BM077R 1
14 Foerster Sponge FCPS BF122R 4
15 Edna Towel Clamp BF461R 12
16 Rochester-Pean Forceps BH445R 2
17 Kocher-Ochsner Forceps BH644R 2
18 Kocher Retractor 1 - Prong BT234R 1
19 Kocher - Langenbeck Retr BT354R 2
20 Kocher - Langenbeck Retr BT359R 2
21 Kocher Retractor BT371R 2
22 Bone Elevator 17 MM FK166R 2
23 Bone Elevator 25 MM FK176R 2
24 Langenbeck Raspatory MB279R 1
25 Bergmann mallet FL055R 1
26 Beyer Bone Rongeur FO514R 1
27 Roettgen - ruskin Bone Rongeur FO521R 1
28 Dissect. Forseps BD031R 1
29 Lange - Hohmann Elevator FK161R 1
30 Kocher Retractor 1 - Prong BT239R 1
31 Langenbeck Elevator FK130R 1
32 Volkmann Bone Curette no. 0 FK633R 1
33 Bristow Bone Lever 230MM FK140R 1
34 Yankaeur Suction Cannula GF944R 1
35 Kidney Trey 250 mm JG506R 1
36 Kidney Trey 275 mm JG508R 1
37 Laboratory Dish 0.063 L JG521R 1
38 Laboratory Dish 0.16 L JG522R 1
39 Laboratory Dish 0.4 L JG523R 1
40
41
42
43
44
CSSD Pcs OT
Date Packet : Date Used :
Checked by : Theatre :
Discripancies 1st 2nd
Scrub Nurse
Circulating Nurse
Discripancies
 Checklist Surgical Instrument Set

Name Of Set : TURP / Cystoscopy

NO ITEMS CODE CSSD Qty Checker
Pack Std OT CSSD
1 Foerstar Sponge FCPS BF 122 R 3
2 Towel Clamp BF 461 R 3
3 Laboratory Dish JG 521 R 1
4 Laboratory Dish JG 522 R 1
5 Guyon catheter Guide EF 492 R 4

CSSD Pcs OT
Date Packet : Date Used :
Checked by : Theatre :
Discripancies 1st 2nd
Scrub Nurse
Circulating Nurse
Discripancies
 Remarks

OT
 Checklist Surgical Instrument

Name Of Set : LSCS II

NO ITEMS CODE CSSD Qty Checker
Std OT
1 Mayo Safety BF493R 2
2 Scaple Handle No 4 BB084R 1
3 Scaple Handle No 3 BB073R 1
4 Standard Forceps BD050R 1
5 Tissue Forceps BD549R 2
6 MC'Indoe Tissue Forceps BD661R 1
7 MC'Indoe Del Thumb Forceps BD236R 1
8 Yankauer Suction Canulle GF944R 1
9 Foerster Sponge Forceps BF122R 5
10 Edna Towel Clam BF461R 5
11 Surgical Scissors BC325R 1
12 Mayo - Lexer Scissors BC592R 1
13 Mayo Scissors BC547R 1
14 TC Metzenbaum Scissors BC263R 1
15 Toennis - Adson Scissors BC631R 1
16 Rochester - Pean Forceps BH445R 5
17 Kocher - Ochsner Forceps BH644R 2
18 Fritsch Abdominal Retractor No 3 BT657R 1
19 Simpson C-Section Forceps ET245R 1
20 Kocher Retractor BT459R 1
21 Laboratori Dish JG521R 2
22 Kidney Tray 175 mm JG504R 1
23 Kidney Tray Stainless Stell 250 mm JG506R 1
24 Kidney Tray 275 mm JG508R 1
25 spong holding ZEPF 2
26 Mosquito Forceps Lawton 1
27 Needle Holder Jermany Stenlis 1
28 Needle Holder zepf 2
29 langen back Rinox 1

CSSD Pcs OT
Date Packet : Date Used :
Checked by : Theatre :
Discripancies
Scrub Nurse
Circulating Nurse
Discripancies
nt

Checker Remarks
CSSD

Pcs OT
 1st 2nd

ting Nurse

CSD 0305.05 /1