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Anesthesia Record
Procedure
Allergies
OR TIMES
START
ANESTH
OP
FINISH
ANESTH
OP
Patient Identity verified
Chart Reviewed
Consent signed
NPO Since_________AM/PM
Time Out Conducted
Pneumatic Comp to LE
Patient Safety
• • •
Eye Care
• • •
TYPE OF ANESTHESIA
GENERAL
• • •
MAC
• • •
PREANESTHETIC VITAL SIGNS
BP
P
R
Temp
O2 SAT
Antibiotics given to pt within 30mins of incision
ANESTHESIA PROVIDER
• • •
Others, please specify
SIgnature
SURGEON
IV(s)
• • •
Others, please specify
Angio No___________G
PREANESTHETIC STATE
AGENTS
O2 L/M
1.______________
2.______________
3.______________
4.______________
5.______________
6.______________
7.______________
8.______________
9.______________
10.______________
11.______________
12.______________
13.______________
14.______________
TOTALS
N2O L/M
1.______________
2.______________
3.______________
4.______________
5.______________
6.______________
7.______________
8.______________
9.______________
10.______________
11.______________
12.______________
13.______________
14.______________
TOTALS
ISO / SEVO
1.______________
2.______________
3.______________
4.______________
5.______________
6.______________
7.______________
8.______________
9.______________
10.______________
11.______________
12.______________
13.______________
14.______________
TOTALS
DEMEROL (MG)
1.______________
2.______________
3.______________
4.______________
5.______________
6.______________
7.______________
8.______________
9.______________
10.______________
11.______________
12.______________
13.______________
14.______________
TOTALS
MIDAZOLAM (MG)
1.______________
2.______________
3.______________
4.______________
5.______________
6.______________
7.______________
8.______________
9.______________
10.______________
11.______________
12.______________
13.______________
14.______________
TOTALS
FENTANYL (MCG)
1.______________
2.______________
3.______________
4.______________
5.______________
6.______________
7.______________
8.______________
9.______________
10.______________
11.______________
12.______________
13.______________
14.______________
TOTALS
PROPOFOL
1.______________
2.______________
3.______________
4.______________
5.______________
6.______________
7.______________
8.______________
9.______________
10.______________
11.______________
12.______________
13.______________
14.______________
TOTALS
SUX/ VEC/PANC.
1.______________
2.______________
3.______________
4.______________
5.______________
6.______________
7.______________
8.______________
9.______________
10.______________
11.______________
12.______________
13.______________
14.______________
TOTALS
ANCEF/CLINDA/GENT
1.______________
2.______________
3.______________
4.______________
5.______________
6.______________
7.______________
8.______________
9.______________
10.______________
11.______________
12.______________
13.______________
14.______________
TOTALS
REGLAN/ZOFRAN
1.______________
2.______________
3.______________
4.______________
5.______________
6.______________
7.______________
8.______________
9.______________
10.______________
11.______________
12.______________
13.______________
14.______________
TOTALS
GLYCO/ATROPINE
1.______________
2.______________
3.______________
4.______________
5.______________
6.______________
7.______________
8.______________
9.______________
10.______________
11.______________
12.______________
13.______________
14.______________
TOTALS
Graph scale
POSTOP NOTE
VENTILATOR
TV
RR
PIP
INTRAOP NOTES
FLUIDS
LR
1.______________
2.______________
3.______________
4.______________
5.______________
6.______________
7.______________
8.______________
9.______________
10.______________
11.______________
12.______________
TOTAL FLUID
NS
1.______________
2.______________
3.______________
4.______________
5.______________
6.______________
7.______________
8.______________
9.______________
10.______________
11.______________
12.______________
TOTAL FLUID
MONITORS
EKG
1.______________
2.______________
3.______________
4.______________
5.______________
6.______________
7.______________
8.______________
9.______________
10.______________
11.______________
12.______________
TOTAL FLUID
O2 SATURATION
1.______________
2.______________
3.______________
4.______________
5.______________
6.______________
7.______________
8.______________
9.______________
10.______________
11.______________
12.______________
TOTAL FLUID
END TIDAL CO2
1.______________
2.______________
3.______________
4.______________
5.______________
6.______________
7.______________
8.______________
9.______________
10.______________
11.______________
12.______________
TOTAL FLUID
TOTAL URINE OUTPUT
EBL
*Anesthesia “start time” begins when the first Blood Pressure is cycled
*Anesthesia “end time” is when the patient exits the OR for transfer to recovery

DrChrono Plastic Surgery | Anesthesia Record Medical Form

Plastic Surgeon

DrChrono's anesthesia record form, customizable for your Plastic Surgery practice.

There are 5 copies in use.
Published: Dec. 11, 2018, 3:41 p.m.
Doctor: Dr. History Physical
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