SAFETY INJECTION ASSESSMENT SHEET Hospital:…………………………… Assessment No.: …………… Hospital department: Cardiology and Respiratory Pediatric Surgery Ophthalmology Pathobiology and pulmonology Otolaryngology Internal medicine Intensive care Obstetric facial and orthodontics Observation time: day ………….hour……… ……….month………..year………. Name of health worker who injected :………………………………………………. Name of observer:……………………………………………………………………. A- General information a1. Patient’s name: ………………………………………………………………….. a2. Patient’s age: ………………………………………………………………….. A3. Injection time: A4. Router of A5. Injection location: Morning administration: Delta Mechanical; Noon Intravenous injection; Quadriceps thigh; Afternoon Deep intramuscular Arm trilum;
SAFETY INJECTION ASSESSMENT SHEET Hospital:…………………………… Assessment No.: …………… Hospital department: Cardiology and Respiratory Pediatric Surgery Ophthalmology Pathobiology and pulmonology Otolaryngology Internal medicine Intensive care Obstetric facial and orthodontics Observation time: ………….hour……… day ……….month………..year………. Name of health worker who injected :………………………………………………. Name of observer:……………………………………………………………………. A- General information a1. Patient’s name: ………………………………………………………………….. a2. Patient’s age: ………………………………………………………………….. A3. Injection time: Morning Noon Afternoon A4. Router of administration: Intravenous injection; Deep intramuscular A5. Injection location: Delta Mechanical; Quadriceps thigh; Arm trilum;
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