ANESTHESIA 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]