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ANESTHESIA RECORD Procedure Anesthesia


Date OR No. Page of Surgeon(s) Procedure
PRE-PROCEDURE MONITORS AND EQUIPMENT ANESTHETIC TECHNIQUE AIRWAY MANAGEMENT RECOVERY
Identfied: ID Band Questioning Steth: Precord Esoph Other General: Pre-Oxygenation LTA Intubation: Oral Tube size Location Time
Chart Reviewed Permit Signed Non-Invasive B/P: Left Right Rapid Sequence Cricoid Pressure Stylet Used Nasal Regular
NPO Since Continuous EKG V Lead EKG Intravenous Inhalation Magill's Direct RAE B/P O2 Sat.
Pre-Anesthetic State: Calm Pulse Oximeter Oxygen Sensor Intramuscular Rectal Fiber Optic Blind Armored
Awake Asleep End Tidal CO2 Gas Analyzer Regional: Spinal Epidural Blade Laser P R T
Apprehensive Confused Temp. Nerve Simulator Axillary Bier Block Ankle Block Secured at cm Endobronch.
Uncooperative Unresponsive Warming Blanket EEG Doppler Position Attempts x ET CO2 Present Awake Stable Nasal Oxygen
PATIENT SAFETY Airway Humidifier Fluid Warmer Prep Local Breath Sounds Drowsy Unstable Mask Oxygen
Anes. Machine # Checked NG / OG Tube Foley Catheter Needle Uncuffed, Leaks at cm H2O Somnolent Intubated T-Piece Oxygen
Safety Belt On Axillary Roll Art. Line Drug(s) Cuffed Min. Occ. Pres. Air NS Unarousable Ventilator Oral/Nasal Airway
Armboard Restraints Arms Tucked CVP Dose Attempts x Airway: Oral LMA Nasal Difficult, Recovery Notes
Pressure Points Checked and Padded PA Line Site Level Circuit: Circle NRB See Remarks
Eye Care: Ointment Saline IV(s) Catheter See Remarks Mask Case Nasal Cannula
Taped Pads Goggles Other: MAC Via Tracheostomy Simple O2 mask

TIME:
Oxygen (L/min) FLUID TOTALS
N2O Air (L/Min) TOTALS Crystalloid EBL
Blood Urine
FLUIDS / AGENTS

REMARKS

Urine (ml)
EBL (ml)

EKG
SYMBOLS
MONITORS

% O2 Inspired
O2 Saturation
ANESTHESIA
End Tidal CO2
Temp: ºC ºF

OPERATION

Baseline
200
Values B/P CUFF
PRESSURE
180

160

ARTERIAL LINE
140 PRESSURE

120
B/P
MEAN ARTERIAL
100 PRESSURE

80

PULSE
P
60

40 SPONT. RESP.

R
20

ASSISTED RESP.

Tidal Volume
VENT

Resp. Rate
Peak Pressure CONTROLLED
RESP.
PEEP
Symbols for Remarks
TOURNIQUET
Position

PATIENT IDENTIFICATION Anesthesia Provider

Drug Issued Used Returned Provider


CONTROLLED
DRUGS

Witness

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