MEDICAL RECORD - ANESTHESIA

For use of this form, see AR 40-66; the proponent agency is the OTSG
DRUG (Units) TOTALS TOTAL EBL
( )
( )
( ) TOTAL URINE
( )
( )
( )
VOLAT % del FLUIDS - SUMMARY
AGENT % e.t. CRYSTALLOID-
AIR L/Min
N2O L/Min COLLOID-
O2 L/Min
SINGLE DOSE DRUGS-MARK ON GRID BLOOD-
►
WITH NUMBERS & ENTER IN REMARKS
LINE site Warmed REMARKS
Warmed Code drugs with numbers,
events with lettters
Warmed
Warmed
EST BLOOD LOSS
LOSSES
URINE -
PHYS STATUS TIME -►
12345 E
SYMBOLS:
BODY WEIGHT: 220
KG BP by cuff
LB 200

HEMATOCRIT: 180
Heart rate

•
160
INITIAL DATA:
Resp rate 140
BP-
/ 120
HR- BR
(transduced) 100

EQUIP CHECK 80

OK?- TOURNIQUET 60
PATIENT RECHECK T 40
OK for
PROCEDURE? ANES- X-X 20
PROC-
TIME-
VT - ml
ANESLABEL130LABEL131LABEL134
INFUSION<>PROC
"I"=CONSTANT
MG/MCG/ML,
-
UNITS
SPECIFY
DRUGS
DRUGSMONITORS/ACCESSORIESCONTINUOUS/REPEATED
AND
AGENTS
VENTILFLUIDSANESTHETIC
f - breaths/min
Peak inf pres / PEEP
MODE - S(pon), A(ssist), C(on) RECOVERY AT
BP/Auto Cuff ET CO2 (torr) (Specify)
PACU ICU
BP/oth FlO2 (Frac or %)
SpO2 (%) OTHER
ART line
Steth- PC/ES ECG CONDITION:

Gas analyzer TEMP-site RESP- SpO2-

N-M Block (T/4) BP- HR-

ANESTHESIA / PROCEDURE
TIMES
Start Room End

Warming blkt
Conv warmer Ready Begin End
Mark with letters & symbols, EVENTS ►
explain under REMARKS Position
PROCEDURES and CPT Codes: ANESTHETIC TECHNIQUES: Describe block technique under Remarks

PATIENT IDENTIFICATION: Typed or written entries: Name, Grade/Rate, AIRWAY MANAGEMENT: Intubation route, blade, technique, comments
Medical facility

SURGEONS: PROCEDURE
LOCATION:
DATE:
ANESTHETISTS:
PAGE OF

DA FORM 7389, FEB 1998 COPY 1 - PATIENT'S MEDICAL RECORD APD LC v1.00
 MEDICAL RECORD - ANESTHESIA
For use of this form, see AR 40-66; the proponent agency is the OTSG
DRUG (Units) TOTALS TOTAL EBL
( )
( )
( ) TOTAL URINE
( )
( )
( )
VOLAT % del FLUIDS - SUMMARY
AGENT % e.t. CRYSTALLOID-
AIR L/Min
N2O L/Min COLLOID-
O2 L/Min
SINGLE DOSE DRUGS-MARK ON GRID BLOOD-
►
WITH NUMBERS & ENTER IN REMARKS
LINE site Warmed REMARKS
Warmed Code drugs with numbers,
events with lettters
Warmed
Warmed
EST BLOOD LOSS
LOSSES
URINE -
PHYS STATUS TIME -►
12345 E
SYMBOLS:
BODY WEIGHT: 220
KG BP by cuff
LB 200

HEMATOCRIT: 180
Heart rate

•
160
INITIAL DATA:
Resp rate 140
BP-
/ 120
HR- BR
(transduced) 100

EQUIP CHECK 80

OK?- TOURNIQUET 60
PATIENT RECHECK T 40
OK for
PROCEDURE? ANES- X-X 20
PROC-
TIME-
VT - ml
ANESLABEL130LABEL131LABEL134
INFUSION<>PROC
"I"=CONSTANT
MG/MCG/ML,
-
UNITS
SPECIFY
DRUGS
DRUGSMONITORS/ACCESSORIESCONTINUOUS/REPEATED
AND
AGENTS
VENTILFLUIDSANESTHETIC
f - breaths/min
Peak inf pres / PEEP
MODE - S(pon), A(ssist), C(on) RECOVERY AT
BP/Auto Cuff ET CO2 (torr) (Specify)
PACU ICU
BP/oth FlO2 (Frac or %)
SpO2 (%) OTHER
ART line
Steth- PC/ES ECG CONDITION:

Gas analyzer TEMP-site RESP- SpO2-

N-M Block (T/4) BP- HR-

ANESTHESIA / PROCEDURE
TIMES
Start Room End

Warming blkt
Conv warmer Ready Begin End
Mark with letters & symbols, EVENTS ►
explain under REMARKS Position
PROCEDURES and CPT Codes: ANESTHETIC TECHNIQUES: Describe block technique under Remarks

PATIENT IDENTIFICATION: Typed or written entries: Name, Grade/Rate, AIRWAY MANAGEMENT: Intubation route, blade, technique, comments
Medical facility

SURGEONS: PROCEDURE
LOCATION:
DATE:
ANESTHETISTS:
PAGE OF

DA FORM 7389, FEB 1998 COPY 2 - ANESTHESIA PROVIDER APD LC v1.00

 MEDICAL RECORD - ANESTHESIA
For use of this form, see AR 40-66; the proponent agency is the OTSG
DRUG (Units) TOTALS TOTAL EBL
( )
( )
( ) TOTAL URINE
( )
( )
( )
VOLAT % del FLUIDS - SUMMARY
AGENT % e.t. CRYSTALLOID-
AIR L/Min
N2O L/Min COLLOID-
O2 L/Min
SINGLE DOSE DRUGS-MARK ON GRID BLOOD-
►
WITH NUMBERS & ENTER IN REMARKS
LINE site Warmed REMARKS
Warmed Code drugs with numbers,
events with lettters
Warmed
Warmed
EST BLOOD LOSS
LOSSES
URINE -
PHYS STATUS TIME -►
12345 E
SYMBOLS:
BODY WEIGHT: 220
KG BP by cuff
LB 200

HEMATOCRIT: 180
Heart rate

•
160
INITIAL DATA:
Resp rate 140
BP-
/ 120
HR- BR
(transduced) 100

EQUIP CHECK 80

OK?- TOURNIQUET 60
PATIENT RECHECK T 40
OK for
PROCEDURE? ANES- X-X 20
PROC-
TIME-
VT - ml
ANESLABEL130LABEL131LABEL134
INFUSION<>PROC
"I"=CONSTANT
MG/MCG/ML,
-
UNITS
SPECIFY
DRUGS
DRUGSMONITORS/ACCESSORIESCONTINUOUS/REPEATED
AND
AGENTS
VENTILFLUIDSANESTHETIC
f - breaths/min
Peak inf pres / PEEP
MODE - S(pon), A(ssist), C(on) RECOVERY AT
BP/Auto Cuff ET CO2 (torr) (Specify)
PACU ICU
BP/oth FlO2 (Frac or %)
SpO2 (%) OTHER
ART line
Steth- PC/ES ECG CONDITION:

Gas analyzer TEMP-site RESP- SpO2-

N-M Block (T/4) BP- HR-

ANESTHESIA / PROCEDURE
TIMES
Start Room End

Warming blkt
Conv warmer Ready Begin End
Mark with letters & symbols, EVENTS ►
explain under REMARKS Position
PROCEDURES and CPT Codes: ANESTHETIC TECHNIQUES: Describe block technique under Remarks

PATIENT IDENTIFICATION: Typed or written entries: Name, Grade/Rate, AIRWAY MANAGEMENT: Intubation route, blade, technique, comments
Medical facility

SURGEONS: PROCEDURE
LOCATION:
DATE:
ANESTHETISTS:
PAGE OF

DA FORM 7389, FEB 1998 COPY 3 - ANESTHESIA DEPARTMENT APD LC v1.00