; Anesthesia Record of Clinical events
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Anesthesia Record of Clinical events

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anesthesia provides the necessary function for surgical patients. while anesthesia is used, it is provider's primary role to document the events of the patient and the actual happening as it occurs in real time, concurrent with the vitals, assessments, and prognosis are factors the provider assesses on the continuum

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									                                                                                 ANESTHESIA RECORD
Date:                      Patient                                                Surgeon(s)
                                                                                                                                                                     START     STOP
OR No.                                                                            Procedure(s)
                           Page ___of___         PATIENT INFORMATION                                                                                 ANESTHESIA
               PRE-PROCEDURE               Age         Sex         Ht       Wt       MONITORS & EQUIPMENT            ANESTHETIC TECHNIQUE
                                                                                                                                                     PROCEDURE
 Pt Identified  Chart Reviewed                                                   Stethoscope:      Precordial   GENERAL:  Intravenous
                                           B/P         P           R        T         Esophogeal     Other         Inhalation  Intramuscular          AIRWAY MANAGEMENT
 Consent      NPO since
   Signed        ___________                                                       Noninvasive B/P:  L  R         Pre-Oxygenation  LTA     INTUBATION:  Oral  Nasal
Pre-Anesthesia State:  Calm               Allergies                               Continuous EKG  Temp______      Rapid Sequence  Rectal    Direct  Stylet Used  Blind
 Awake          Asleep                                                           Pulse Oximeter  NG / OG Tube    Cricoid Pressure           Tube & Size__________________
                                           Medications
 Apprehensive  Confused                                                          End Tidal CO2  Fluid Warmer REGIONAL:  Spinal              Blade _____________  Laser
 Uncooperative  Unresponsive                                                     V Lead EKG        Gas Analyzer  Epidural  Axillary       Attempts x ____ Secured at ____cm
                PATIENT SAFETY             Positive Hx/Med. Problems               Nerve Stimulator                 Bier Block  Ankle Block   Breath Sounds _______________
 Anesthesia machine checked                                                       Foley Catheter                   Position________________  Uncuffed, leaks at _____cm H2O
 Pressure points checked & padded                                                 Airway Humidifier                Local__________________  Cuffed  Min. occlusive pressure
 Safety Belt On  Axillary roll                                                   IV(s) ______________________  Drug(s)________________ AIRWAY:  Oral             Nasal
 Arms tucked       Restraints                  ASA       1   2    3   4   E
                  
								
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