An anesthesia record follows one patient from the pre-anesthesia check to recovery: the assessment, the plan, every drug and dose, the airway or block, each event, and the handover. Copy the free template, see a general anesthetic for gallbladder surgery with sleep apnea and a spinal for a hip fracture on apixaban, and use the short version as a procedural sedation note.
Blank anesthesia record template
FreeANESTHESIA RECORD Patient: [Name, age, sex, record number] Date: [Date] Location: [Hospital, operating room or procedure room] Procedure: [Planned procedure, side, and surgeon or proceduralist] Urgency: [Elective, urgent, or emergency] Anesthesia clinician: [Name, credentials, role; supervising anesthesiologist, if any] PRE-ANESTHESIA ASSESSMENT Weight and height: [Weight in kg, height, BMI; ideal or lean body weight if used for dosing] ASA physical status: [I to VI, with E for an emergency, and the conditions behind the class] Relevant history: [Heart, lungs, sleep apnea, kidneys, diabetes, reflux, and how well each is controlled] Previous anesthesia: [Past anesthetics and problems: difficult airway, severe nausea, slow waking; family history of malignant hyperthermia] Medications: [Current list; anticoagulants with last dose date and time; GLP-1 receptor agonist last dose] Allergies: [Drugs, latex, chlorhexidine, with the reaction to each] Fasting: [Last solids and last clear fluids, with times] Airway exam: [Mallampati class, mouth opening, thyromental distance, neck movement and circumference, teeth, beard] Results: [What matters today, with dates: hemoglobin, potassium, creatinine, glucose, ECG, drug levels] PLAN AND CONSENT Anesthetic plan: [General, spinal, epidural, nerve block, or sedation; the backup] Airway plan: [First device, backup devices ready, and preoxygenation method] Monitoring and access: [Standard monitors plus extras, such as an arterial line, and why] Risks discussed: [General and patient-specific risks, and the patient's questions] Consent: [Who consented, capacity, interpreter if used, time] INDUCTION AND AIRWAY Times: [In room, anesthesia start, induction or block] Monitors and access: [ECG, blood pressure cuff or arterial line, SpO2, end-tidal CO2, temperature, neuromuscular monitor, processed EEG; IV size and site] Position: [Supine, ramped, sitting, or lateral; head-up angle; padding] Induction drugs: [Each drug, dose, time, and the weight it was based on] Airway: [Mask ventilation grade, device and size, blade, grade of view, attempts, depth at lips, how placement was confirmed] Neuraxial or regional block: [Position, level, needle, drug, concentration, volume, dose, block height reached] MAINTENANCE AND EVENTS Maintenance: [Agent and concentration, infusions, ventilator settings] Antibiotic: [Drug, dose, time, and minutes before incision] Other drugs: [Analgesics, antiemetics, vasopressors, relaxant top-ups, each with dose and time] Fluids and output: [Crystalloid, blood products in units, estimated blood loss agreed with the surgeon, urine output] Events: [Each event with time, what was seen, what was done, and the response] Temperature: [Lowest and final temperature, warming used] Relief and handovers: [Who took over during the case, when, and what was handed over, or none] Surgical times: [Incision and end of surgery] EMERGENCE AND HANDOVER Reversal: [Agent, dose, time, and train-of-four ratio before extubation] Emergence: [Extubation time and position, airway and oxygen afterward] Leaving the room: [Time, level of consciousness, breathing, vital signs] Handover to recovery: [Who received the patient, time, drugs given and when, concerns, when to call anesthesia] POST-ANESTHESIA NOTE Pain: [Score at rest and on movement; drugs given in recovery] Nausea and vomiting: [None, or episodes and treatment] Vital signs: [BP, heart rate, breathing rate, SpO2 and oxygen, temperature] Breathing events: [Apneas, desaturation, airway support needed, or none] Block and mental status: [Sensory level and leg movement after a spinal or epidural; orientation; delirium screen] Complications: [Sore throat, dental injury, recall, headache, or none] Discharge score: [Aldrete or other score, out of 10, with the time] Disposition: [Home with an adult, ward, monitored bed, or intensive care, and why] Orders: [Pain relief, oxygen or CPAP, anticoagulant restart, what should prompt a call to anesthesia] Signed: [Name, credentials, date and time]
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Each one follows the template. Use them to judge how much detail every part needs.
Day surgery unit, general anesthetic with an endotracheal tube, ASA III
52-year-old man for elective laparoscopic cholecystectomy for symptomatic gallstones, booked as day surgery. 128 kg, 175 cm, BMI 41.8; ideal body weight 71 kg, lean body weight 75 kg. Obstructive sleep apnea, AHI 38 on a 2024 sleep study, on CPAP 10 cm H2O nightly; he brought his machine. Hypertension on amlodipine 10 mg, taken this morning. No reflux, diabetes, or chest pain; climbs 2 flights of stairs slowly. Previous anesthesia: knee arthroscopy in 2019, whose record notes two-handed mask ventilation with an oral airway, then easy intubation. No family history of anesthesia problems. No GLP-1 receptor agonist. No known allergies. Fasting: light meal at 19:00 last night, water until 05:30. Airway: Mallampati III, mouth opening 4 cm, thyromental distance 6.5 cm, neck circumference 47 cm, full extension, full beard, own teeth. Hemoglobin 14.8 g/dL, 148 g/L; creatinine and potassium normal; ECG sinus rhythm. BP 142/86, heart rate 78, SpO2 95% on room air. ASA physical status III: BMI over 40 and sleep apnea on CPAP.
General anesthetic with an endotracheal tube. Ramped, head up 30°, preoxygenation by face mask with high-flow nasal oxygen left on through intubation. Video laryngoscope first; bougie and a second-generation supraglottic airway ready; two people for mask ventilation. Induction drugs on lean or ideal body weight, antibiotic and reversal on actual weight. Opioid-sparing pain relief: acetaminophen, ketorolac, dexamethasone, and local anesthetic at the ports. Nausea prevention with dexamethasone and ondansetron. Quantitative train-of-four monitoring, sugammadex reversal, awake extubation sitting up. Risks discussed: sore throat, dental damage, nausea, and breathing problems after surgery with sleep apnea, with a chance of staying overnight if they happen in recovery. He asked whether he would need his CPAP in recovery; yes, whenever he sleeps. He agreed. Consent signed at 07:15.
In room 07:35; anesthesia start 07:38. Monitors: 5-lead ECG, large adult cuff on the upper arm, SpO2, end-tidal CO2, temperature, and quantitative train-of-four on the left ulnar nerve. 18-gauge IV, left forearm. Ramped to ear level with the sternal notch, head up 30°. Preoxygenated 4 minutes to end-tidal O2 0.90, nasal oxygen 15 L/min. Induction 07:46: fentanyl 100 micrograms, propofol 150 mg, 2 mg/kg lean body weight. Mask ventilation grade 3: two hands and an oral airway, as in 2019. Rocuronium 50 mg, 0.7 mg/kg ideal body weight. Intubated 07:49: Macintosh-blade video laryngoscope, size 4, grade 1 view, first pass, 7.5 mm cuffed tube at 23 cm at the lips, cuff pressure 25 cm H2O. End-tidal CO2 trace and breath sounds on both sides. Lowest SpO2 98%.
Sevoflurane 1.8 to 2.2% in oxygen and air, FiO2 0.5. Volume control 500 mL, 7 mL/kg ideal body weight, PEEP 10 cm H2O, rate 14, end-tidal CO2 36 to 42 mmHg. Cefazolin 3 g at 07:55, the dose for 120 kg or more, 15 minutes before incision. Dexamethasone 8 mg at 07:55; acetaminophen 1 g IV at 08:00; fentanyl 50 micrograms at 08:10; rocuronium 10 mg at 08:32 for a train-of-four count of 2; ketorolac 30 mg and ondansetron 4 mg at 08:45. Surgeon infiltrated the ports with bupivacaine 0.25%, 20 mL. Events: 07:52, BP 86/48 after induction; phenylephrine 100 micrograms twice, 116/70 by 07:56. 08:14, peak airway pressure 34 cm H2O and SpO2 94% on insufflation in reverse Trendelenburg; recruitment maneuver, and insufflation lowered from 15 to 12 mmHg with the surgeon; peak 28, SpO2 97%. Lactated Ringer’s 900 mL. Blood loss 20 mL, agreed with the surgeon. Urine not measured, no catheter; voided at 07:10. Temperature lowest 36.2 °C, 36.5 °C at the end, forced-air warmer. No relief. Incision 08:10; end of surgery 08:56.
Sevoflurane off 08:58. Train-of-four count 3: sugammadex 260 mg, 2 mg/kg actual body weight, at 08:59; ratio 0.96 at 09:03. Sat up to 45°; eyes open, following commands, regular breaths of about 450 mL. Extubated awake at 09:06; face mask 6 L/min, SpO2 96%. Out of room 09:14. Handover at 09:20 to the recovery nurse: severe sleep apnea, CPAP 10 cm H2O whenever he sleeps, his machine at the bedside; mask ventilation needed two hands and an oral airway, intubation easy with a video laryngoscope; fentanyl 150 micrograms in all, last at 08:10; acetaminophen at 08:00 and ketorolac at 08:45, next doses not before 14:00 and 14:45; dexamethasone and ondansetron given. Head up and continuous SpO2. For pain, hydromorphone 0.2 mg IV every 10 minutes if needed, up to 0.6 mg, only while awake. Home today only if there are no breathing events in recovery.
Pain 6 of 10 at the ports and right shoulder at 09:40; hydromorphone 0.2 mg IV at 09:45 and 09:55; 3 of 10 at rest since. No nausea. 10:20, while dozing: 3 apneas of 15 to 20 seconds, SpO2 down to 86 to 88%, each needing a shake to wake him. CPAP 10 cm H2O on, no further events. At 11:30: BP 136/82, heart rate 76, breathing 14, SpO2 93% on room air awake, 36.6 °C. No sore throat, dental injury, or recall. Aldrete 10 of 10 at 11:30. Disposition: not home today, despite the score, because of recurrent apneas with desaturation after opioids. Admitted overnight to a monitored surgical bed with continuous pulse oximetry, head up 30°, and CPAP whenever asleep. Orders: acetaminophen 1 g every 6 hours; ketorolac 15 mg IV every 6 hours for 24 hours; oxycodone 5 mg by mouth only for pain of 7 or more, with SpO2 monitoring; no sedatives. Surgeon and patient told; home tomorrow if the night has no events.
Urgent orthopedic list, spinal anesthetic with a fascia iliaca block, ASA III
84-year-old woman for a cemented right hemiarthroplasty for a displaced femoral neck fracture. Fell at home at 07:00 on Sunday, on the floor under an hour; admitted 08:30. 52 kg, 158 cm, BMI 20.8. Atrial fibrillation on apixaban 2.5 mg twice daily, the reduced dose for age 80 or more and weight 60 kg or less; last dose 20:00 Saturday. Hypertension. No angina, heart failure, or fainting; no murmur, and a 2025 echocardiogram showed normal left ventricular function and no aortic stenosis. Walks with a cane; lives alone with a daily home care visit. Previous anesthesia: general anesthetic for a hysterectomy in 1994, nausea for a day. Metoprolol 25 mg twice daily, taken at 06:00 with a sip of water; amlodipine held. No known allergies. Fasting: solids at 18:00 Sunday; clear fluids until 07:30. Airway: Mallampati II, full dentures removed, mouth opening 3 fingerbreadths, neck extension reduced. Back: mild kyphosis, spinous processes easy to feel. Monday 07:00: hemoglobin 11.8 g/dL, 118 g/L; platelets 214; creatinine 1.0 mg/dL, 88 µmol/L, creatinine clearance 34 mL/min; potassium 4.2 mmol/L; group and screen done. Apixaban-calibrated anti-Xa level 21 ng/mL, 35 hours after the last dose. ECG atrial fibrillation, rate 78. 4AT 0. ASA physical status III.
Spinal anesthetic with no sedation, after a fascia iliaca block for positioning; general anesthetic as the backup. Neuraxial timing: at 52 kg and a creatinine clearance of 34 mL/min, her apixaban counts as a high-dose regimen under current regional anesthesia guidance, which asks for 72 hours off, or a drug-specific level below 30 ng/mL. Her level is 21 ng/mL, so a spinal is acceptable now; waiting the full 72 hours would push surgery past 48 hours from admission. Radial arterial line for cementing. Risks discussed: low blood pressure, headache, nerve injury, rare bleeding around the spine, and confusion after surgery. She has capacity: she explained the plan back in her own words and agreed. Her daughter joined by phone. Consent signed at 08:40.
In room 09:05. Monitors: 5-lead ECG, cuff every 3 minutes until the arterial line, SpO2, end-tidal CO2 by nasal cannula sampling, temperature. 18-gauge IV in the left forearm from the emergency department; 20-gauge right hand. Oxygen 2 L/min by nasal cannula. 09:12: right suprainguinal fascia iliaca block under ultrasound, ropivacaine 0.2%, 40 mL, 80 mg, 1.5 mg/kg. 09:20: right radial arterial line, 20-gauge, under local. 09:30: sitting, L3-L4 midline, 25-gauge pencil-point needle, second pass, clear fluid, no blood or paresthesia. Hyperbaric bupivacaine 0.75%, 1.2 mL, 9 mg, with fentanyl 15 micrograms. Laid supine; block to T10 to cold on both sides at 09:42. 09:45: left lateral, right side up, pressure points padded. No sedation: awake and talking, with her own music. Airway not instrumented.
Phenylephrine infusion from 09:35 at 20 micrograms a minute, range 10 to 40, for mean arterial pressure 65 or more and systolic within 20% of her baseline of 146. Lowest 104/56 at 09:48, then 126/62 after the rate was raised. Cefazolin 2 g at 09:40, 20 minutes before incision. Tranexamic acid 1 g at 09:55. Acetaminophen 1 g IV at 10:05. Event, 10:42: cement, announced by the surgeon, with oxygen already raised to 8 L/min by face mask. Arterial pressure 128/64 to 98/50, down 23%, and SpO2 97% to 92% within a minute: grade 1 bone cement implantation syndrome. Phenylephrine 100 micrograms twice; 124/62 and SpO2 96% by 10:46; oxygen back to 2 L/min at 11:00. Lactated Ringer’s 750 mL. Blood loss 350 mL, agreed with the surgeon. Urine 150 mL, catheter from the emergency department. Point-of-care hemoglobin 10.1 g/dL, 101 g/L, at 11:00; no transfusion, with a threshold of 8 g/dL, 80 g/L, or symptoms. Temperature lowest 36.2 °C, 36.5 °C at the end, forced-air warmer from arrival. No relief. Incision 10:00; end of surgery 11:12.
No emergence needed: awake and oriented throughout. Phenylephrine off at 11:05. Out of room 11:20, on her back with a pillow between the knees, oxygen 2 L/min; arterial line kept for recovery. Handover at 11:25 to the recovery nurse: apixaban last taken 20:00 Saturday, level 21 ng/mL; spinal at 09:30 with bupivacaine 9 mg and fentanyl 15 micrograms, expected to wear off by 13:00 to 14:00; fascia iliaca block at 09:12; grade 1 cement reaction, resolved; acetaminophen at 10:05; no IV opioids; hemoglobin 10.1 g/dL. Call anesthesia for a systolic pressure below 100, SpO2 below 92%, or new confusion.
At 12:15: pain 0 of 10 at rest, 2 on moving the leg; no drugs needed. No nausea. BP 126/64 by arterial line, heart rate 84 in atrial fibrillation, breathing 14, SpO2 95% on room air, 36.6 °C. Block: sensory level L1 to cold; moves both feet, can’t yet lift either knee. Oriented, glasses and hearing aids on; 4AT 0. No complications beyond the cement reaction. Aldrete 9 of 10 at 12:15, the point lost only for leg movement under the spinal. Disposition: orthopedic ward at 12:30; arterial line removed. Orders: leg checks every hour until full strength returns, expected by 15:00; new weakness, numbness, or back pain after that, call anesthesia at once. Acetaminophen 1 g every 8 hours; oxycodone 2.5 mg by mouth every 4 hours if needed; no benzodiazepines; delirium precautions; out of bed with physiotherapy tomorrow. Hemoglobin in the morning. Enoxaparin 40 mg subcutaneously at 08:00 Tuesday, more than 12 hours after the spinal; apixaban 2.5 mg twice daily restarts at 08:00 Thursday in place of enoxaparin if there is no bleeding, as agreed with the orthopedic team.
The check on the day, or in the clinic before it, that sets the anesthetic: fitness, airway, fasting, and the medicines that change the plan.
Avoid: Copying the clinic assessment forward. Check what changed since: a new medicine, a missed CPAP night, breakfast this morning.
The anesthetic you chose, the backup, and what the patient agreed to after hearing the risks that matter for them.
Avoid: “Risks explained, consent obtained.” Name the risks, above all the ones this patient carries, such as breathing problems after surgery with sleep apnea.
How the anesthetic started: monitors, access, each drug with its dose and time, and exactly how the airway was managed or the block placed.
Avoid: “Airway: easy, ETT.” The next anesthetic is planned from this line. Give the device, the view, and the number of attempts.
What kept the patient anesthetized and stable: every drug, what went in and came out, and each event as it happened.
Avoid: A summary written at the end. Events and doses recorded later lose their times, and the times are what a review checks first.
How the patient woke or came out of the block, and what the recovery team was told.
Avoid: Leaving out opioid times. Recovery staff dose from your handover; without the times, patients get a double dose or none.
The recovery check: pain, nausea, vital signs, any complication, a discharge score, and where the patient goes next, with the reason.
Avoid: Letting the score decide. Write the reason for the disposition, such as apneas in recovery, even when the score is 10.
In obesity, induction drugs, relaxants, antibiotics, and reversal agents are dosed on different weights. Write each dose and the weight behind it, so the next clinician can check it.
The next anesthetic is planned from this one’s notes. Record the mask ventilation grade, the device and blade, the grade of view, the attempts, and any adjunct. If the airway was difficult, tell the patient and their regular clinician.
A fall in blood pressure written up at the end as “hemodynamically stable” disappears from the record. Write the time, the value, what you did, and the response as it happens.
Before a spinal, epidural, or deep block, record the drug, dose, last dose date and time, the interval your guidance asks for, and any drug level. Then record when it restarts.
An Aldrete score of 9 or 10 says the patient can leave recovery. It doesn’t say a patient with apneas can go home, or that a spinal has worn off. Write the disposition and the reason.
Recovery staff act on your handover. Give the drugs with their times, the airway, your concerns, and when to call, in the same order every time.
Vero Scribe drafts the anesthesia record in your template from the pre-anesthesia visit, with the patient’s consent, or from your dictation after the case. You review and edit every section, then copy it into your record or export it to Word or PDF. Vero works in 60+ languages.
The pre-anesthesia assessment: ASA physical status, an airway exam with the Mallampati class, fasting times, allergies, medicines with the last anticoagulant dose, past anesthetic problems, and the results that matter. Then the plan and consent; each drug with dose and time; the airway device and grade of view, or the block and its level; fluids, blood loss, and urine output; timed events and what was done; emergence and handover; and a post-anesthesia note with pain, nausea, vital signs, a discharge score, and where the patient went.
Use the same record, shortened. Before: the indication, ASA physical status, airway exam, fasting times, consent, and the depth of sedation you plan. During: who gave the sedation and who monitored, SpO2, end-tidal CO2, blood pressure at least every 5 minutes, each drug with dose and time, the depth reached, and any event, such as a fall in SpO2 and the airway step that fixed it. After: return to baseline, a discharge score, and the adult who takes the patient home.
The surgeon writes the operative note: findings, each surgical step, specimens, and implants. The anesthesia clinician writes the anesthesia record: fitness for anesthesia, drugs, the airway or block, vital signs, fluids, events, and the handover to recovery. Both record blood loss and times, and the two should agree.
SpO2 and ECG are monitored continuously, and end-tidal CO2 under general anesthesia and most sedation. Blood pressure is measured at least every 5 minutes, and more often after induction, a spinal, or a sudden change. An electronic record captures the numbers; your part is to record what caused a change, what you did, and the response.
Many units use the Aldrete score, out of 10, with 9 or more to leave recovery. For going home after day surgery, some add the Post-Anesthetic Discharge Scoring System, also out of 10, with 9 or more. Neither covers apneas in a patient with sleep apnea, a spinal that hasn’t worn off, or no adult to take the patient home, so record those decisions in words.
Yes. Copy it, or download it as a Word or text file. No account needed.
Pre-anesthesia notes and post-anesthesia follow-up, drafted from your conversations for review.
Common codes for the conditions behind an anesthetic.
Consultations, patient instructions, and follow-up after surgery.
Vero writes your notes and letters in the templates you choose, so you review instead of type.
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