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Pre-Anesthesia Evaluation
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NPO
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ASA
• • •
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PRE-OP DIAGNOSIS
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PROCEDURE(S)
• • •
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If other Procedures, select "other" and specify:
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NEUROLOGICAL
• • •
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If other Neurological, select "other" and specify:
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GI/ GU/ RENAL/ HEMA
• • •
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If other GI/GU/Renal/Hema, select "other" and specify:
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RESPIRATORY
• • •
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If other Respiratory, select "other" and specify:
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ENDOCRINE
• • •
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If other Endocrine, select "other" and specify:
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AIRWAY MAL
• • •
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TEETH
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FROM
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CV: RRR
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PULM: CTA
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Notes
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CARDIOVASCULAR
• • •
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If other Cardiovascular, select "other" and specify:
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MUSCULOSKELETAL/OTHER
• • •
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If other Musculoskeletal/other, select "other" and specify:
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Past surgical/ anesthesia history reviewed?
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Complications?
• • •
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Other complications comments
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Anesthesia Plan Explained & Understood. Consent Obtained and On File?
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Initials
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Anesthesia Pre-Evaluation Completed by:
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CNA
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MD
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Anesthesia Record
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IV Gauge
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IV Site
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Performed by
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Difficult Access?
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Prior Attempts?
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Sterile Technique
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SAFETY CHECK
• • •
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TYPE OF ANESTHESIA
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Select all that apply
• • •
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POSITION
• • •
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AIRWAY
• • •
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Airway additional comments
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Anesthesia Start
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Anesthesia Start Free Text
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Time Out
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Time Out Free Text
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Surgery Start
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Surgery Start Free Text
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Surgery Stop
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Surgery Stop Free Text
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GRAPH
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POSTOPERATIVE DIAGNOSES
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INTRAOPERATIVE NOTES
• • •
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PACU
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BP
/
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P
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R
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SaO2 (%)
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Report to:
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Level
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DISCHARGE NOTE
• • •
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CRNA Signature
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MD Signature
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Anesthesia Team
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CRNA
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MD
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Location
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