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ANESTHESIA RECORD

Case No: OR Suite No. Date:


Last Name: First Name MI

AGE SEX STATUS HEIGHT WEIGHT HEMATOCRIT HEMOGLOBIN BLOOD TYPE

PREOPERATIVE FINDINGS: PREOPERATIVE DIAGNOSIS


BP PR RR TEMP

CARDIOVASCULAR OPERATION PROPOSED: CONSENT


RESPIRATORY
CENTRAL NERVOUS SYSTEM PRE MEDICATION DOSE ROUTE TIME
ENDOCRINE
PREVIOUS ANESTHETIC EXPERIENCE
ALLERGIES
LAST MEAL
POSITION RISK 1 2 3 4 5
HOURS TOTAL FLUIDS GIVEN

AGENTS TOTAL BLOOD GIVEN


0XYGEN L/MIN

FLUIDS URINE OUTPUT

BLOOD X ANESTHESIA STARTED

PULSE 180 X OPERATION STARTED


RESP 180
TEMP 140 X OPERATION ENDED
CVP 120
SYST 100 MAINTENANCE
BP
80
DIAS
BP 60
ANESTHETIC AGENT
40

20
SYMBOLS
DETAILED TECHNIQUE CONDITION OF PATIENT ON DEPARTURE FROM OR ( ) TO MAIN WARD/ICU
( ) TO RECOVERY ROOM
GOOD FAIR POOR GUARDED
OROTRACHEAL _______ NASOTRACHEAL _______ CUFF _______ UNDER MASK _______ BLIND _______ NASOPHARYNGEAL AIRWAY _______
RECOVERY REFLEX IN OR YES __ NO __ RETCH ___ RES OBS TR. EMESIS _____ PUL VENT ____ EXCIT M.S.T.O.F. _______ HEAD LIFT _______
OPERATION: __________________________________________________________________________________________________________
POATOPERATIVE DIAGNOSIS: _____________________________________________________________________________________________
SURGEON: ________________________________________ NURSES: _________________________________________________
ASSISTANT: _______________________________________ SIGNATURE OF ANESTHESIOLOGIST: ___________________________