ANESTHESIA RECORD ANESTHESIA RECORD
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1 PROCEDURE SURGEON(S) ANESTHESIA PROVIDER(S) DATE: OR # IV GAUGE SITE R L ANESTHESIA TECHNIQUE: GEN - REG - IV Sed - L/MAC ASA PRIOR TO INDUCTION ANESTHESIA TIME INITIAL E START: STOP: Started OR / Floor PRE-MEDICATION & TIME: UNCHANGED CHANGED (see notes) TIME OUT" PERFORMED (Correct Patient, Correct Procedure, Correct Side/Site, Correct Position, Special Anesthesia Equipment) O2 L/M N2O / Air L/M desflurane/sevoflurane % IV Fluids EBL UOP TIME MONITORS & EQUIPMENT 200 NIBP R L q min 180 O2/N20/Agent Airway Humidifier Blanket Warmer 160 Upper / Lower Fluid Warmer 140 OG / NG # Fr 120 Steth PC / ESO TE Monitor 100 SYMBOLS O Operation 80 NIBP Arterial BP 60 PULSE 40 VENTILATION O Spontaneous 20 O Assisted OX Mechanical REMARKS EKG FIO2 SpO2 ETCO2 TEMP VT / PIP POSITION REMARKS: TOTALS Test Dose: See Remarks PATIENT CONTROLLED DRUGS SAFETY DRUG WASTE anesthesia machine # checked ARMS restraints at side ABD less than 90 EYES taped lubed provider signature witness signature goggles RECOVERY AIRWAY Location: PACU - CCU NP O2 mask Mask Airway O / N LMA # Time in: RA - NP - FM - LMA - ETT Awake - Responsive - Not Responsive ETT / NTT # md BP: P: Endobronchial # Fr L R: T: INTUBATION Blind Direct - blade SpO2: % O2: L/M Notes: # Trachlight Fiberoptic Easy Difficult (see notes) REGIONAL Spinal Epidural Other: Position: Prep: Local: Needle: Drug(s)/Dose: Site: Attempts x Level: Catheter:
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3 PROCEDURE SURGEON(S) ANESTHESIA PROVIDER(S) DATE: OR # IV GAUGE SITE R L ANESTHESIA TECHNIQUE: GEN - REG - IV Sed - L/MAC ASA PRIOR TO INDUCTION ANESTHESIA TIME INITIAL E START: STOP: Started OR / Floor PRE-MEDICATION & TIME: UNCHANGED CHANGED (see notes) TIME OUT" PERFORMED (Correct Patient, Correct Procedure, Correct Side/Site, Correct Position, Special Anesthesia Equipment) O2 L/M N2O / Air L/M desflurane/sevoflurane % IV Fluids EBL UOP TIME MONITORS & EQUIPMENT 200 NIBP R L q min 180 O2/N20/Agent Airway Humidifier Blanket Warmer 160 Upper / Lower Fluid Warmer 140 OG / NG # Fr 120 Steth PC / ESO TE Monitor 100 SYMBOLS O Operation 80 NIBP Arterial BP 60 PULSE 40 VENTILATION O Spontaneous 20 O Assisted OX Mechanical REMARKS EKG FIO2 SpO2 ETCO2 TEMP VT / PIP POSITION REMARKS: TOTALS Test Dose: See Remarks PATIENT CONTROLLED DRUGS SAFETY DRUG WASTE anesthesia machine # checked ARMS restraints at side ABD less than 90 EYES taped lubed provider signature witness signature goggles RECOVERY AIRWAY Location: PACU - CCU NP O2 mask Mask Airway O / N LMA # Time in: RA - NP - FM - LMA - ETT Awake - Responsive - Not Responsive ETT / NTT # md BP: P: Endobronchial # Fr L R: T: INTUBATION Blind Direct - blade SpO2: % O2: L/M Notes: # Trachlight Fiberoptic Easy Difficult (see notes) REGIONAL Spinal Epidural Other: Position: Prep: Local: Needle: Drug(s)/Dose: Site: Attempts x Level: Catheter:
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5 PROCEDURE SURGEON(S) ANESTHESIA PROVIDER(S) DATE: OR # IV GAUGE SITE R L ANESTHESIA TECHNIQUE: GEN - REG - IV Sed - L/MAC ASA PRIOR TO INDUCTION ANESTHESIA TIME INITIAL E START: STOP: Started OR / Floor PRE-MEDICATION & TIME: UNCHANGED CHANGED (see notes) TIME OUT" PERFORMED (Correct Patient, Correct Procedure, Correct Side/Site, Correct Position, Special Anesthesia Equipment) O2 L/M N2O / Air L/M desflurane/sevoflurane % IV Fluids EBL UOP TIME MONITORS & EQUIPMENT 200 NIBP R L q min 180 O2/N20/Agent Airway Humidifier Blanket Warmer 160 Upper / Lower Fluid Warmer 140 OG / NG # Fr 120 Steth PC / ESO TE Monitor 100 SYMBOLS O Operation 80 NIBP Arterial BP 60 PULSE 40 VENTILATION O Spontaneous 20 O Assisted OX Mechanical REMARKS EKG FIO2 SpO2 ETCO2 TEMP VT / PIP POSITION REMARKS: TOTALS Test Dose: See Remarks PATIENT CONTROLLED DRUGS SAFETY DRUG WASTE anesthesia machine # checked ARMS restraints at side ABD less than 90 EYES taped lubed provider signature witness signature goggles RECOVERY AIRWAY Location: PACU - CCU NP O2 mask Mask Airway O / N LMA # Time in: RA - NP - FM - LMA - ETT Awake - Responsive - Not Responsive ETT / NTT # md BP: P: Endobronchial # Fr L R: T: INTUBATION Blind Direct - blade SpO2: % O2: L/M Notes: # Trachlight Fiberoptic Easy Difficult (see notes) REGIONAL Spinal Epidural Other: Position: Prep: Local: Needle: Drug(s)/Dose: Site: Attempts x Level: Catheter:
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7 Anesthesiology Department ANESTHESIA QUALITY ASSURANCE BOLDED ITEMS FALL OUT FOR PEER REVIEW Initial: CODE 0100 AIRWAY 0101 Aspiration 0102 Dental Injury 0103 Difficult Intubation (unrecognized) 0104 Esophageal Intubation 0105 Hypoxemia (SpO2 less than 90%) sustained 5 min 0106 Mainstem Intubation 0107 Post-intubation Croup 0108 Reintubation (unplanned) 0109 Respiratory Arrest (unplanned) 0110 Unable to intubate 0111 Uvular Trauma OR PACU 48 HRS OR PACU 48 hrs 0200 CARDIOVASCULAR 0201 Pulmonary Edema 0202 Cardiac arrest 0203 Dysrhythmia (new dx d) 0204 Myocardial Infarction Acute (new) 0205 Pulmonary Embolism 0300 DEATH 0301 Temporally Related to Anesthetic CODE 0600 INVASIVE MONITORS 0601 Post-CVC Pneumothorax 0602 Carotid artery Puncture 0603 Pulmonary Hemorrhage with Swan Ganz OR PACU 48 HRS 0700 MISCELLANEOUS 0701 Burns 0702 Ocular Injury 0703 Post-TURP Syndrome 0704 Recall 0800 NEUROLOGICAL 0801 Nerve Palsy 0802 Seizures 0803 Spinal Headache 0804 Stroke (new) 0900 REGIONAL TECHNIQUE 0901 Epidural Wet Tap 0902 Failed Block 0903 High Level 0904 IV Local Injection (unplanned) 0905 Pneumothorax 0400 DRUG 0401 Muscle Paralysis Prolonged (unplanned) 0402 Narcotic Resp Depression (Rx d with Narcan) 1000 THERMOREGULATION 1001 Malignant Hyperthermia 1002 Core Temp less than 95 F (unplanned) 0500 EQUIPMENT 0501 Failure (See other side) DISPOSITION QUALITY MANAGEMENT 1100 TYPE OF ANESTHETIC DELIVERED 1101 Other than planned ANESTHESIA QUALITY ASSURANCE DATE: ANESTHESIA TIME ANESTHESIA CHARGES START: STOP: CODE AMOUNT DESCRIPTION ANESTHESIA INITIAL 15 MINUTES ANESTHESIA EA ADDL MINUTE US GUIDE VASC ACCESS US GUIDE NEEDLE PLACEMENT HEMOCUE DISPOSITION: HMC BILLING OFFICE ANESTHESIA CHARGES
8 Description of Incident (Reference Code) MD/CRNA Signature:
9 PRE - ANESTHETIC EVALUATION PROPOSED PROCEDURE CURRENT MEDICATIONS DIAGNOSIS Age Height Weight Date: temp pulse resp SpO2 BP lb(s)/ RA Time: O2 kg SURGICAL / ANESTHETIC HISTORY no personal or family history of anesthetic complications ALLERGIES / NKDA CBC LABORATORY STUDIES CXR DIAGNOSTIC STUDIES TEETH RESPIRATORY Asthma COPD Recent URI Sleep Apnea Smoker packs/day x yrs Ex-Smoker packs/day x yrs CARDIOVASCULAR Angina ASHD / CAD ASPVD CHF Dysrhythmia HTN HEPATO / GASTROINTESTINAL Hiatal Hernia / Reflux Drug / Alcohol Abuse Liver Disease Nausea / Vomiting Ulcers Appear normal Decayed Missing Other Dentures Full: Upper / Lower Partial: Upper / Lower AIRWAY / HEAD & NECK Quit Hypercholesterolemia / Hyperlipidemia MI Pacemaker Valvular Disease No apparent airway problems WNL WNL WNL Electrolytes Na K Other WBC Hgb Hct Platelets Cl CO2 NPO after: time BUN Creatinine Glucose date EKG Other ANESTHESIA PLAN ASA E Anesthesia Plan: GEN - REG - IV Sed - L/MAC Anesthesia plan, risks, benefits and alternatives discussed with patient. Questions were answered. Yes No Patient appears to understand; anesthetic plan and risks are accepted. Patient wishes to proceed and is determined to be an appropriate candidate for the planned anesthesia. Yes No NEURO / MUSCULOSKELETAL Arthritis Neuropathy WNL Patient identity, procedure, and site verified. Yes No CVA / TIA's DJD Paralysis Seizures provider signature date / time Headaches POST-OP VISIT Muscle Weakness Neuromuscular Disease RENAL / ENDOCRINE Diabetes: NIDDM / IDDM Renal Failure / Dialysis Recent Steroids WNL Chart reviewed Patient visit No apparent anesthetic complications signature date / time Thyroid Disease OTHER Coagulopathy Obesity Pregnancy Psychiatric Hx PRE-ANESTHETIC EVALUATION
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