MED-FM-032/Rev.

1/01May2024

Republic of the Philippines

Department of Health
MAYOR HILARION A. RAMIRO SR. MEDICAL CENTER
Maningcol, Ozamiz City
DEPARTMENT OF ANESTHESIOLOGY

PRE-OPERATIVE ANESTHESIA EVALUATION CHECKLIST

Hospital No._____________________________
NAME:
Age: Sex: Weight: kg Height: cm
Vital Signs: BP: CR: RR: SpO2:
DIAGNOSIS:
PROCEDURE:
BP______ HR______ RR______ SPO2_______
PRE-ANESTHETIC ASSESSMENT
HISTORY: PHYSICAL EXAMINATION:
Relevant Medical History: ¨ Airway assessment: Normal/Difficult
¨ Diabetes Mellitus ¨ Mouth Opening: >2 Fingers
¨ Hypertension ¨ Thyromental Distance >Fingers
¨ Bronchial Asthma ¨ Full Neck movement
¨ Others: __________ ¨ Maltampati: I II III IV
Anesthetic History:

Medications:

Allergy:____________
¨ Smoker______ cig/day for ______years
HEAD AND NECK CHEST ABDOMEN
¨ Pink palpebral conjunctiva ¨ Symmetrical chest expansion ¨ Flat
¨ Pale palpebral conjunctiva ¨ Asymmetrical chest expansion ¨ Globular
¨ Anicteric sclerae ¨ Clear breath sounds ¨ Distended
¨ Icteric Sclerae ¨ Crackles ¨ Soft
¨ Mass ¨ Ronchi ¨ Rigid
¨ Others: ¨ Murmurs ¨ Tenderness
¨ Others ¨ Others:

EXTREMITY
 Deformity of Extremities
 Grossly normal
 Edema
 Others:

LAB RESULTS:
Na:________ Hgb:________ PT:_______%
K:_________ Hct:________ INR:______
Crea:_______ Plt:_________ Blood sugar:_______
Urea:_______ WBC:______
ANETHESIA PLAN:

ASA STATUS: 1 2 3 4 5 E
 MED-FM-027/Rev.1/01May2024

Republic of the Philippines

Department of Health
MAYOR HILARION A. RAMIRO SR. MEDICAL CENTER
Maningcol, Ozamiz City
DEPARTMENT OF ANESTHESIOLOGY

ANESTHESIA RECORD
Hospital No: Name: Age: Birthdate:
o Male
o Female
Date: Diagnosis:
Co-morbids
ASA: 1 2 3 4 5 E O2 @ __LPM via ____
PREMEDICATION
Main

VITAL SIGNS
Supplementary

BP HR
RR T
GCS
Wt. Ht.
SERVICE TECHNIQUE
GS GETA
OB GA-
LMA
IVInfusions

ENT GA-
MASK
OPHTH GA-RA
A
ORTHO SAB EBL
CLEA UO
AIRWAY CSEA ECG
Monitors

FM/NC TIVA SpO2

GA MAC etCO2
Mask
LMA PNB Temp
Tracheo NEEDLES X Induction 220

DL Quincke g ⊤ Intubation 210

VL Touchy g ʘ Start.
200
⊗ End
⊥ Extubation
Ø Assisted
⃝ Controlled
● Pulse
INDUCTION ꓦ Systolic BP
Preoxygenate w/ ꓥ Diastolic BP
DL x Mac/ Mil 〇┛Supine
C-L gr. size 〇┓Prone
LMA /ETT /DLT Size 〇┛Lithotomy 〇
＿| Left Up.
o SCE
〇＿| R Right Up
o Clear
Positive etCO2
o Secured at level
o Asepsis M / PM x
o Blood o Paresthesia
o CFF CSF
o LORTA o TD
S Block lvl EC in ES
 MED-FM-027/Rev.1/1Feb2024

Remarks:

Position:
ANESTHESIOLOGIST SURGEONS
Main Assist Main Assist

Republic of the Philippines

Department of Health
MAYOR HILARION A. RAMIRO SR. MEDICAL CENTER
Maningcol, Ozamiz City
DEPARTMENT OF ANESTHESIOLOGY
ANESTHESIA RECORD
Hospital No: Name: Age: Birthdate:
o Male
o Female
Date:
ASA: 1 2 3 4 5 E O2 @ __LPM via ____
VITAL SIGNS
BP HR
Main

RR T
GCS
Wt. Ht.
Supplementa

DELIVERY
AS at 1 min
AS at 5 mins
AS at 10 mins
RECOVERY
Reversal: Y N NA
IVInfus

BP HR
RR T
GCS
POST-OP PAIN MEDS EBL
UO
Monitors

ECG
SpO2
etCO2
Temp
BLOOD LOSS X Induction 230
10% EBV 10-20% ⊤ Intubation 220
20-20% 30-40% ʘ Start. 210
40-50% >50% EBV ⊗ End
200
FLUID SUMMARY ⊥ Extubation
190
Total crystalloids Ø Assisted
180
Total colloids ⃝ Controlled
170
BLOOD ● Pulse
160
Whole Blood ꓦ Systolic BP
150
Packed RBC ꓥ Diastolic BP
140
FFP 〇┛Supine
130
Platelet Concentrate 〇┓Prone 120
〇┛Lithotomy 〇
110
＿| Left Up 100

R Right Up
〇＿|
90
80
Critical Events 70
60

50
40
30
20

10
0
Remarks
Post Operative Diagnosis:

Procedure (s) Done:

Hospital No: Name: (SURNAME, FIRST NAME MIDDLE INITIAL) Age: Birthdate:
o Male
o Female
Date: Diagnosis:

Comorbidity:
ASA: 1 2 3 4 5 E O2 @ __LPM via ____
PREMEDICATION
Main

VITAL SIGNS
Supplementary

BP HR
RR T
GCS
Wt. Ht.
SERVICE TECHNIQUE

GS GETA
IVInfusions

OB GA-LMA
ENT GA-MASK

OPHTHA GA-RA
ORTHO SAB EBL
CLEA UO
Monitors

AIRWAY CSEA ECG

FM/NC TIVA SpO2
GA Mask MAC EtCO2
LMA PNB Temp
Tracheo NEEDLES X Induction 230
DL Quincke g ⊤ Intubation 220
VL Touhy g ʘ Start.
210
⊗ End
200
⊥ Extubation
190
Ø Assisted 180
⃝ Controlled
170
INDUCTION ● Pulse
160
Preoxygenate w/ ꓦ Systolic BP
150
DL x Mac / Mil ꓥ Diastolic BP 140
CL gr. size 〇┛Supine
130
LMA /ETT /DLT Size 〇┓Prone 120
o SCE 〇┛Lithotomy 〇
110
o Clear ＿| Left Up 100

Positive EtCO2 90

o Secured at level R Right Up

〇＿| 80
o Asepsis M / PM x
o Blood o Paresthesia
o CFF CSF
o LORTA
S Block lvl EC in ES

Remarks
ANESTHESIOLOGIST SURGEONS

Main Assist Main Assist