Anesthesia Record

Patient ID # Height Weight Pulse Resp. BMI Age Fasted

¨ Yes ¨ No
Surgeon Surgical Assistant Anesthesiologist Anesth. Assistant Date Check
¨ Yes
Drugs in the last 24 hours:

Medication Dosage Route Time

Preanesthetic
Induction

Type Time
Fluids
Monitors

Complications 0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80
¨ 200 Comments
¨
¨ 180
¨
¨ 160
¨
Airway 140
¨ Mask
¨ Trach 120
¨ ET Tube
¨ LMA 100
¨ Oral
80
Symbols
+ Pulse 60
¦ Resp.
˄ Systolic 40
˅ Diastolic
X Start 20
X Stop
0

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