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  • Anaes Notes

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    Dr.Vaibhav Kamath
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    This document summarizes a patient's pre-operative checkup, anesthesia record, and post-operative status. It includes the patient's name, diagnosis, operating surgeon, anesthetist, pre-op exam findings, investigations, ASA grading, anesthesia technique used, monitoring, anesthesia administration details, regional anesthesia if used, vital signs monitoring during and after the procedure, and post-op assessment. The record provides essential information about the patient's condition and anesthesia for a surgical procedure.

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    This document summarizes a patient's pre-operative checkup, anesthesia record, and post-operative status. It includes the patient's name, diagnosis, operating surgeon, anesthetist, pre-op exam findings, investigations, ASA grading, anesthesia technique used, monitoring, anesthesia administration details, regional anesthesia if used, vital signs monitoring during and after the procedure, and post-op assessment. The record provides essential information about the patient's condition and anesthesia for a surgical procedure.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOC, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as doc, pdf, or txt
    12 views3 pages

    Anaes Notes

    Uploaded by

    Dr.Vaibhav Kamath
    This document summarizes a patient's pre-operative checkup, anesthesia record, and post-operative status. It includes the patient's name, diagnosis, operating surgeon, anesthetist, pre-op exam findings, investigations, ASA grading, anesthesia technique used, monitoring, anesthesia administration details, regional anesthesia if used, vital signs monitoring during and after the procedure, and post-op assessment. The record provides essential information about the patient's condition and anesthesia for a surgical procedure.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOC, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as doc, pdf, or txt
    of 3

    Anaesthesia Records

    Date: Time: Name: Diagnosis: Operating Surgeon: Anesthetist: Pre-Operative Check-up History: Examination: GeneralPallor: Cyanosis: Clubbing: M.P.C. Grade: Mouth Opening: o Respiratory System: Air Entry: o Cardiovascular System: Heart Sounds: o Neurological Status: Higher Functions: Motor: Sensory: Bladder/ Bowel: Investigations: o o o o o o HbT.L.C.BUN: Sr. Creat: A.S.T.: A.L.T. F.B.S: P.L.B.S: C.X.R.: Special Investigations: E: M: P: Na: K: Cl: Bili. Total: Direct: HIV: HBSAg: E.C.G.: L: IPD no: Age/Sex: Operation/ Procedure: Wt:

    Icterus: Tooth:

    Oedema: Neck movements: Added Sounds: Murmurs:

    A.S.A. Grading: I / II/ III/ IV / V / E Informed Consent: Starvation: Anaesthesia Technique: I.V. Lines: Monitoring: SPO2/BP/ ECG/ EtCO2/ Temp Anaesthesia: GA/ SA/ Epidural / Regional Block / TIVA / LA Position: Pre-medication:

    Regional Anaesthesia: o Type: Subarachnoid / Epidural / Brachial Plexus / o Level: Needle: Approach: o Drug: Batch No.: o Level Achieved: General Anaesthesia: Induction: Intubation: Maintenance:

    o o o

    0Hr 200 180 160 140 120 100 80 60 40 20 0 o Reversal: o Extubation:

    1Hr

    2Hr

    3Hr

    4Hr

    5Hr

    Post- Operative: Pulse: / min B.P.: / mm of Hg R.R.: /min Level: % SpO2: Head Lift: Responds to: o Advice:

    Level:

    Signature

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