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Pretreatment Medications
• • •
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Other
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Dose
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Time
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Initials
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Prep
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Pre-Operative :
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Time
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BP
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Temp
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Loc
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O2SAT
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Tumescent Local Anesthesia calc
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Patient Weight
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Lbs x 1KG / 2.2lbs
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KG Body Weight
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KG x 55MG/KG =
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MG Maximum Lidocaine Dose
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Max Dose Lidocaine/400 MG/L
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L Tumescent Fluid
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Lidocaine w/EPI 1:1,000,000 admi
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Anesthesian start time
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Anesthesian end time
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Procedure start time
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Procedure end time
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Treatment #
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Area Treated
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Lower Abdomen
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Upper Abdomen
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Flank
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Back
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Hip
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Buttocks
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Lateral Thighs
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Medial Thighs
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Knees
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Calves
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Midsuprascapular
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Axillary
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Facial / Neck
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Axilary Anterior
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Axilary Posterior
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Nitrous
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continuous O2 monitoring
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Complication
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Amount of time administered
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Notes :
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Effect
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Side effect
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Other
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Fat Transfer
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Area
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Photo taken
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Photos Taken
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Recovery Vital signs
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Time
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HR
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LOC
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discharge home with adult
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Pre-op diagnosis
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Anesthesia
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BP
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David R Milstein MD
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RR
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Notes
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Post-op diagnosis
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Procedure Suction
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Complications
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