PATIENT LABEL

Name : Age : Sex : M / F

MRN : Bed No.
Consultant :

ANAESTHESIA
AND
SURGICAL NOTES
 PATIENT LABEL
Name : Age : Sex : M / F
MRN : Bed No.
Consultant :

CONSENT FORM FOR SURGERY / PROCEDURE

INSTRUCTIONS : This consent from should be signed by patient if an adult (18 years and above), by parent/guardian if
the patient is a minor, by the spouse or adult children or parents or adult brothers or sisters or other family member or
significant other ( in this order of priority ) if the patient lacks the ability to make an informed decision. The physician or
his designee doctors are responsible for obtaining consent.

1. I hereby authorize the performance of the following operation(s), procedure(s) or treatment(s) {hereafter
referred to as procedures}: (Use no abbreviation / Avoid Technical Terms).
____________________________________________________________________________________________
__________________________________________________________________________________________U
pon_________________________________________________________________________(Name of Patient)
2. I have been advised of the benefits and reason of the procedure(s) as indicated by the clinical observations and
or diagnostics performed. I recognize that the practice of medicine is as much an art a science and therefore
acknowledge that no guarantees have been or can be made regarding the likelihood of success or outcomes.
Benefits are listed as follows :
____________________________________________________________________________________________
____________________________________________________________________________________________
_______________________________________See Progress Note.
3. I have been advised that major risks involved in the above procedure(s) are :
____________________________________________________________________________________________
____________________________________________________________________________________________
_______________________________________See Progress Note.
4. I have been advised of the following existing alternatives in treatment and prognosis, if the procedure(s) is not
done are listed as follows :
____________________________________________________________________________________________
____________________________________________________________________________________________
_______________________________________See Progress Note.
5. I authorize Dr. __________________________________ and such assistants and associates as may be selected
by him/her to perform any part of the above procedure(s) upon myself/the patient. I have been advised and
agree that any member of this team may perform any of the procedure(s) according to his/her stage of training
and ability, if in the opinion of the above named physician, the experience and capability of the assistant
surgeon justifies such a decision.
6. As with any procedure. I am aware that risk such as blood, infection, heart failure, change in blood pressure,
anesthetic allergic reactions, paralysis etc. may arise necessitating attention. Therefore in addition to consenting
to the performance of the padicular procedure(s), I also consent and authorize the rendering of such other care
and treatment as the physician or his designee reasonably necessary should one or more of these and /or other
unforeseeable events occur.
7. Blood or blood product transfusions : This consent includes the administration of blood or blood product
transfusion during this procedure and immediate post-operative period.
 I have been informed that despite careful screening in accordance with national and international regulations,
there are rare instances of life threatening infections such as AIDS, Hepatitis and other viruses or diseases, as yet
unknown, for which screening test do not exists. I also understand that unpredictable reaction may occur, which
include but are not limited to fever, rash and shortness of breath, shock and in rare occasions, death.

Expected benefits of the transfusion may include minimizing shocks, brain and other organ damage, fastening
recovery and limiting blood loss. However, I understand that there are no guarantees offered as to the expected
benefits of the transfusion.
8. Photography : I consent to the photography or televising of the procedure(s)to be performed, for the purpose of
advancing medical education; or its publication in scientific journals, provided my/the patient’s identity is not
revealed by the pictures or description in the accompanying texts. In an effort to further medical Science and
education. I consent to and authorize the presence of and observation of this procedure by qualified observers,
as many be authorized by the Pratiksha Hospital Guwahati and its regulatory laws and agencies.

AUTHORIZATION OF PATIENT

I acknowledge that I have had an opportunity to discuss this procedure, as stated above, with my physician or
physician designee, and hereby consent to this procedure.

Signature Name Date Time

Patient
Witness
Doctor
Interpreter

CONSENT OF PATIENT REPRESENTATIVE / SURROGATE

The patient is unable to consent because : ____________________________________________________________

And I, __________________________________________(name / relationship to the patient), therefore, consent for

the patient, I acknowledge that I have had an opportunity to discuss the procedure, as stated above, with the Doctor
/ doctor’s designee, and hereby consent to the procedure.

Signature Name Date Time

Patient Representative
with relationship
Witness
Doctor
Interpreter
 Barbari, Bishnunagar, VIP Road,
Hengrabari, Guwahati – 36
Telefax : +91(361) 7101600
Ph.: (0) +91(0) 99540-93556
e-mail: info@pratikshahospitals.com

CONSENT FORM FOR ANAESTHESIA

Date : ……………………

I, _________________________________, acknowledge that my doctor has explained to me that I will have an

operation, diagnostic, or treatment procedure. My doctor has explained the risks of the procedure what could happen if
my condition remains untreated. I also understand that anesthesia services are needed so that my doctor can perform
the procedure.

I has been explained to me that all forms of anesthesia involve some risk and no guarantees or promises can be made
concerning the results of my procedure or treatment. Although rare, unexpected severe complications with anesthesia
can occur and include the remote possibility of infection, bleeding, drug reactions, blood clot, loss of sensation, loss of
limb function, paralysis, stroke, brain damage, heart attack or death. I understand that these risks apply to all forms of
anesthesia and that additional or specific risks have been identified below as they may apply to a specific type of
anesthesia. I understand that the type(s) of anesthesia service checked below will be used for my procedure and that
the anesthetic technique to be used is determined by many factors including my physical condition, the type of
procedure my doctor is to do, my doctor’s preference, and my own preference. It has been explained to me that
sometimes an anesthesia technique which involves the use of local anesthetic, with or without sedation, my not succeed
completely and therefore another technique may have to be used including general anesthesia.

Total unconscious state, possible placement of a tube

 General Anesthesia
 Spinal or Epidural analgesis /
Anesthesia
 With sedation
 Without sedation
Expected Result
into the windpipe
Drug injected into the bloodstream, breathed into the
Technique
lungs, or administered by other roots.
Mouth or throat pain, hoarseness, injury to mouth or
Risks teeth, awareness under anesthesia, injury to blood
vessel, aspiration, pneumonia.
Temporary decrease or loss of feeling and / or
Expected Result
movement to lower part of body.
Drug injected through a needle / catheter placed either
Technique directly into the spinal canal immediately outside the
spinal canal.

Headache, backache, buzzing in the ears, convulsions,

Risks infection, persistent weakness, numbness, residual pain,
injury to blood vessels, "total spinal".

Temporary loss of feeling and / or movement of specific

 Major / Minor Nerve Block
 With sedation
 Without sedation
Expected Result
limb or area of the body.
Drug injected near nerves providing loss of sensation to
Technique
the area of the operation.
Infection, convulsions, persistent numbness, residual
Risks
pain, injury to blood vessels.
 Expected Result Reduce anxiety and pain, partial or total amnesia.

 Monitored Anesthesia Care Drug injected into the bloodstream, breathed into the
(with sedation) Techniques lungs, or administered by other routs producing a semi-
conscious state.
An unconscious state, depressed breathing, injury to
Risks
blood vessels.
Measurement of vital signs, availability of anesthesia
Expected Result
 Monitored Anesthesia Care provider for further intervention.
(without sedation) Techniques None
Risks Increased awareness, anxiety and / or discomfort.

I hereby consent to the anesthesia service checked above and authorize that it be administered by
___________________________________________________________________ or his/her associates, all of whom are
credentialed to provide anesthesia services at this healthcare facility. I also consent to an alternative type of anesthesia,
if necessary, as deemed appropriate by them. I expressly desire the following considerations be observed (for write
“none”)

CONSENT OF PATIENT REPRESENTATNE / SURROGATE

The patient is unable to consent because : _______________________________________________________________

and I, ____________________________(name / relationship to the patient),therefore, consent for the patient, I
acknowledge that I have had an opportunity to discuss the procedure, as stated above, with the Doctor / Doctor’s
designee, and hereby consent to the procedure.

Signature Name Date Time

Patient Representative
with relationship
Witness
Doctor
Interpreter (if required)

Information about the patient’s guardian (proxy consent) :

(This clause should be filled and the guardian should sign this consent only in case of incompetent patients i.e. minors,
old aged, unconscious, mentally unfit, disoriented patients)

Name : Mr./Ms./Mrs.

Address :

Phone No. :

Relationship with the patient, if any :

[A person accompanying an unrelated patient should write ‘Unrelated-accompanying’ and when consent is given by
higher authorizes of a hospital, designation such as ‘Medical Superintended’ or ‘Medical Director’ must be written.]
 The likelihood of needing a blood transfusion for this procedure is : Highly unlikely Possible Probable I
understand that there are potential risk from blood transfusions, through rare, and that some of these include
transfusions reaction, hepatitis, and AIDS (Acquired Immune Deficiency Syndrome). Initial in appropriate box:
 I give consent to receive blood or blood products as determined by my anesthetist and doctor to be necessary
for my well-being.
 I give consent to receive blood or blood products only as an emergency life-saving measure.
 I do not want to receive blood or blood products under any circumstances.

BLOOD TRANSFUSIONS

I certify and acknowledge that I have read this form or had it read to me; that I understand the risks,
alternatives and expected results of the anesthesia service; and that I had ample time to ask questions and to
consider my decision.

_______________________________ _____________________________
Patient’s Signature Date and Time

_______________________________ _____________________________
Substitute’s Signature Relationship to Patient
 PATIENT LABEL
Name : Age : Sex :
M/F
MRN : Bed No.

CONSENT FORM FOR ANAESTHESIA

Scheduled date for the proposed intervention / procedure / surgery :

Principal Anesthetist :

Name Dr.

Qualification :

Type’s of anesthesia proposed to be induced :

a. Local c. Spinal
b. General d. Regional Block

I, the undersigned, do hereby state and confirm as follows :

1. I have been explained the following in terms and language that I understand. I have been explained the
following in ………………………………………………… (Name of the language or dialect) that is spoken and
understood by me.
2. I have been explained; I have been provided with the requisite information; I have understood; and
thereafter I consent, authorize and direct the above named principal anesthetist and his / her team
with associates or assistants of his / her choice to induce anesthesia mentioned hereinabove during
the course of the proposed intervention / procedure / surgery and also to administer the requisite
drugs and medications.
3. I have been explained and have understood the importance of preoperative fasting and the risks of
consuming solids / liquids prior to the induction of anesthesia.
4. I have been explained and have understood that including anesthesia has certain material risks /
complications and I have been provided with the requisite information about the same. I have also
been explained and have understood that there are other undefined, unanticipated, unexplainable
risks /compilations that may occur during or after inducing anesthesia.
 PATIENT LABEL
Name : Age : Sex :
M/F
MRN : Bed No.

HIGH RISK CONSENT

I, …………………………………………………………………………………………………………………. have been explained about my

surgery by the doctors and also the causes of my being High Risk are due to the following :

1.
2.
3.

(PATIENT / REPRESENTATIVE)

I also state that I or my family shall not hold Pratiksha Hospital Guwahati or its doctors for any consequences
whatsoever. It has also been explained to me that the EXPENDITURE RATE FOR THE HIGH RISK CASES IS
SUBSTANTLY HIGHER THAN NON-HIGH RISK CASES.

Name of relatives authorizing the surgeon to carry out the operation :

Relationship to the patient :

Signature of Relative :

Time & Date :

Signed in the presence of witness

1.
2.

Signature of doctor who has explained the risk :

Name of Doctor : Date : Time :

NOTE : PLEASE ENTER HIGH RISK STATUS ON THE ACTIVITY ACARD.

 MEDICAL HISTORY

ALLERGIES
PRESENT PROBLEM (List any relevant CVC, Endocrine, Respiratory, Neurological Musculoskeletal, Renal & Hepatic
problem)

 TOBACCO
 ETHANOL

PRE OPERATIVE DIAGNOSIS

List all previous surgeries :
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________
Medication (Prescribed medications, Food and drug allergies/reactions :
over the counter medications) : ____________________________
_____________________________________ ____________________________
_____________Premed :_________________ ____________________________
Taking Beta blockers Latex allergy ______________
Taking Blood thinners Duration ____ Stopped Since ____________

Tick or Do you now have you ever had a history of : Check Do you now have you ever had a history of :
Cross
Cardiovascular Disease Blood Disorder
Chest Pain / Lightness / Heart Attack Abnormal bleeding tendency or taking blood thinners
Irregular Heart Beat / Syncope Sickle cell disease or trait
Pacemaker / Defibrillator Brand:_____________________________ History of blood transfusions.
Problem with circulation Religious or other objections to blood transfusion
Blood clot in legs or lungs Eye- Disorder / Glaucoma / retinal detachment Cataract
High blood pressure
Ear Disorder / "Ringing" In ears / Hearing loss
Other
Respiratory Disease Ear Disorder /"Ringing" in ears / Hearing loss
Smoking ____________packs per day ; Quit __________________ If Yes, Specify
Asthma Psychiatric disorder
Emphysema / bronchitis If yes, Specify
Shortness of breath at rest Other illness or disease
Upper respiratory infection (cold) within 2 weeks If yes, Specify
Sleep apnea Use CPAP For Women
MET Score Could you be pregnant
First day of last Menses
Neurological Disorder Post Menopause / hysterectomy
Stroke or mini-stroke (T.I.A)
Seizures
Back or neck problems Anesthesia Related information
Physical restrictions/limitations Anesthesia within one year
Forgetfulness, memory loss, confusion History of difficult intubation
Multiple sclerosis/muscular dystrophy Any objections to spinal/epidural anesthesia
Never/spinal cord injury Adverse reaction to anesthesia
Neuropathy Relative with Malignant Hyperthermia
Nausea or vomiting after anesthesia
Are you aware of the risk of eating or drinking on the day of your
anesthesia
Diabetes Taking Insulin / Insulin pump Because drugs may interact adversely with anesthesia, please indicate the
following:
Thyroid Problem
History of regular alcohol use or within 24 hours
Kidney / Bladder / Prostate Disorder Use of steroids/cortisone in the past year
If yes, specify _________________________________ History of "street drugs" use or within 30 days
Inability to urinate after anesthesia
Dialysis : Schedule

Gastro-Intestinal Disease
Loose or capped teeth or dentures in place
Liver disease (Jaundice, hepatitis)
Hiatus hernia / reflux / heartburn
Other _________________________________________________
Examination on
Date : ____________ Time : ___________
HR __________________________________________________
BP __________________________________________________
Temp ________________________________________________
RR __________________________________________________
SPO2 on RA ___________________________________________
Respiratory System :
Air Entry _____________________________________________
Ronchi ______________________________________________
Creps ________________________________________________
Breath Holding ________________________________________
Cardiovascular System :
Heart Sounds __________________________________________
Murmur ______________________________________________
_____________________________________________________
Per Abdomen _________________________________________
_____________________________________________________
Central Nervous System :
Sensory ______________________________________________
Motor / Power / Tone ___________________________________
Cranial Nerves _________________________________________
The risks, benefits, and alternatives of GA, Reg. and Loc/Sed have
been Discussed.
The plan is : GA Regional IV Sedation TIVA
MAC
And/or _______________________________________________
Date ____________ Time _________ Signature ______________
Physician -
Reviewed - Patient assessed -
SIGNATURE OF ANESTHESIOLOGIST (pre Anesthesia)
Investigations :
Hb/Hct ____________________________________________
WBC ______________________________________________
Platelet ____________________________________________
Na ________________________________________________
K _________________________________________________
Urea ______________________________________________
Creatinine __________________________________________
PT/PTT ____________________________________________
INR _______________________________________________
LFT _______________________________________________
__________________________________________________
X-RAY _____________________________________________
___________________________________________________
ECG _______________________________________________
___________________________________________________
Echo ______________________________________________
___________________________________________________
Stress Echo _________________________________________
___________________________________________________
Coronary Angina _____________________________________
___________________________________________________
FBS _______________________________________________
Preg Neg Pos
Intubation Assessment
I __________ II _________ III___________ IV ____________
Dentures Caps / Crowns
Overbite Loose teeth
ROM : Full Limited Note
ASA 1 2 3 4 5 6 E
 O.T RECORD
Pre-induction: Comments (if any) : ________________________________
Pulse :________________________________________ _________________________________________________
BP : __________________________________________ _________________________________________________
RR : _________________________________________ _________________________________________________
Chest : _______________________________________ _________________________________________________
_____________________________________________ _________________________________________________
CVS : _________________________________________ _________________________________________________
____ _________________________________________ _________________________________________________
CNS : _________________________________________
_____________________________________________
Temp :________________________________________
Signature :
Spine : _______________________________________
_____________________________________________
Date : Time :
Airway : ______________________________________
_____________________________________________
TIME

Anesthesia Start ________________________ OT Start ___________________________ OT End ____________________________

Leave OT __________________________________________ And Anes _________________________________________________

LINE SIZE AND LOCATION

CVP PA
ART IV
IV IV

INDUCTION

IV INHAL RECTAL IM PRE 02 CRICOID PR

AIRWAY

ORAL NASAL ETT#____________________ AT_____________________ cm

ORAL NASAL TRACHOSTOMY TOPICLA DRUG_____________ % _____________ml

TRACHEAL DRUG ______________________ % _________________________ml

AWAKE RAPID SEQUENCE DIRECT VISION BLIND FIBREOPTIC

STILLETTE/BLADE# _______________________ ATTEMPTS

DIFFICULT WHY ____________________________________________________________________________

BP CUFF SITE EKG LEAD TEMP SITE POSITION OF PATIENT

PRESSURE POINT CRICOID

EYE CARE
OINT TAPETEMP CONTRL
HME BLD WARMER HUGGER LIGHTS BLANKET OTHER
 PATIENT LABEL
Name : Age : Sex :
M/F
MRN : Bed No.

ANESTHESIA RECORD

ANES S1 Start End Res

CARE S2 Start End Res
TEAM S3 Start End Res
Time Total
DRUGS

Mode
Tidal Vol/P
Rate
FIO2

Temp. C/P Time Bp

18 200
16
14

40 12 150
10

8
30 100

6
4
2
30 50
BP
CVP
Pulse
Temp

Position on table
 Respiratory rate
IV Fluid
IV Fluid
Volatile F`1
Volatile F2
O2
N2O/AIR
SpO2
FIO2
ETCO2
Blood loss (Cum)
Urine output

Anesthetist (Please tick where used Apparatus check………….. (Please intial)

Induction Dose Analgesia Dose Muscle Relaxant Dose Monitoring Dose
Atropine Alfentanil Atracurrium BP auto
Glycopyrrolate Fentanyl Cisatracurium Intra-arterial BP
Etomidale Remifentanil Mivacurium ECG
Ketamine Morphine Pencuronlum SPO2
Propofol Pethidine Rocuronium FIO2
Lignocaine NSAID Suxamethonium ETCO2
Thiopentone (Specify) Vecuronium Agent Monitor
Midazolam Other Other PNS
Volatile Temp.
Other CVP/PAC
Vent. Alarm

Maintenance Anti Emetics Reg. Anac. Airway Size Credit Vent

Desflurance Metoclopramide Spinal Face mask Circle Spontaneous
Halothane Ondanseiron Epidural Oral airway Bain IPPV
Isoflurance Granisetron Eye block Copa airway T. Piece Assisted
Sevoflurance Palanosetron IVRA Nasal airway Todal Volume
Oxygen Remosetron Plexus LMA Minute Volume
Air Dexamethasone Local infil ETT Oral PAP
Nitrous Oxide Pharynx ETT Nasal PEEP
Propofol Reversal Nasal Cuffed IE
Glycopyrrolate Other Reinforced Respiratory rate
Naloxone Performed
Neostigmine DLT

Drugs Total Dose Time Sign Drugs/Blood Transfusion Total Dose Time/Sign
Temp. C/P Time Bp
18 200
16
14

40 12 150
10

8
35 100

6
4
2
30 50
BP
CVP
Pulse
Temp
Position on table
Respiratory rate
IV Fluid
IV Fluid
Volatile F1
Volatile F1
O2
N2O/AIR
SpO2
FIO2
ETCO2
Blood Loss (Cum)
Urine output

Peripheral nerve block procedure note

PATIENT NAME - DATE -

ID - AGE - SEX - ASA CATEGORY -
CONSENT - YES / NO
INDICATION - SURGICAL ANESTHESIA / ANALGESIA
SURGERY / SITE
SURGEON
BLOCK PERFORMED
PROCEDURE START TIME / END TIME

VITAL SIGNS 1. NIBP 2. HR - 02 SATURTION -

PREMEDS Midazolam / propofol / ketamine / fentanyl
SKIN PREPN Betadine / alcohol based
Patient positioning Supine / Prone / LLD / RLD / Sitting
Monitors NIBP / SPO2 / ECG / OTHERS
Technique Single shot / catheter insertion continuous
Localization method USG / never stimulator / both
Needle -

Local anesthetic
Motor response Current setting USG pic Conc Volume additives
drug
good Ropivacaine
poor Lignocaine
Pain on injection Y/N
Blood aspiratio Y/N
Resistance on injection Y/N
Events
Block success Complete / partial / failed / aborted.
Post procedure condition BP HR P2 sat
Awake / sedated / comfortable

Remarks Signature

PATIENT LABEL
Name : Age : Sex :
M/F
MRN : Bed No.
 RECOVERY NOTE

Total Fluid Input Total Fluid Output

Cry …………………………………………………………… Urine ……………………………………………………..
Blood ………………………………………………………. Blood ……………………………………………………..
Colloids …………………………………………………… ……………………………………………………………….
Throat pack removed (Please circle) Yes No
Critical Incidents / Comments From Completed (Please circle) Yes No

Actual Operation Performed

ANESTHASIA RECOVERY NOTES

 Duration of Anesthesia:…………………………………………………………………………………………………………………………………............
 Total amount of analgesics used :………………………………………………………………………………………………………………………………
 Reversal of Neuromuscular Blocking Agent (NMBA) :………………………………………………………………………………………………..
 Neostigmine : ………………………………………………………………………………………..
 Glycopyrrolatr : ……………………………………………………………………………………..
 Atropine : ………………………………………………………………………………………………
 Extubated Yes/No
 Elective ventilation Yes/No
 Post Operative condition Conscious / Drowsy / Sedated
 Pulse -
 Blood pressure Anesthesia Summary / Discharge Card
 Pain Score - (NRS) ………………………………………../10
 Sedation Score - (RAMSAY) ……………………………/7 GA / SAB / EA / Plexus Block
O SpO2 LA
 Post OP ICU Transfer (Reason)______________________ ETT / LMA
___________________________________________________ AIRWAY
CL
Signature of Anesthesia : Recovery  Uneventful
 Delayed
……………………………………………………………………………………………………  Emergency
Date : ………………………………………………………………………………………….
Special Comments
Time : ………………………………………………………………………………………...

PATIENT LABEL
Name : Age : Sex :
M/F
MRN : Bed No.
 DESCRIPTION PROCEDURE

Position
Incision

Steps

Sponge / Instrument / Pound / verified Yes No

Wound closure Skin closure

Condition of patient :
Sing : Date : Sign : Date :

Time Time :
Name (Asst. Surgeon/Registrar/M.O.) Name (Surgeon)

Surgeon’s Notes
Date Type Emergency Routine Unpinned return to theater

Procedure Performed Time out Followed

Yes No

Surgeon (s) Assistant (s)

Anesthetist Anesthesia Tourniquet Time

Start Time

End Time

Circulating Nurse Scrub Nurse

Preoperative Diagnosis Preoperative Diagnosis Same

Indications for Procedure

Material forwarded to lab Material forwarded to security (ML Cases only)

HPE
C/S
OTHERS
Drain (s) EBL I/O Prosthesis / Implant label

(Stick any label)

Findings

Signature Intra-operative Events

Doctor Name & Sing

Date :

POST PROCEDURE COMMENTS / INSTRUCTIONS

POST-OPERATIVE ADVICE PLAN
Disposition : Ward Bed No. ____________________ / Critical Care _____________________ Bed No. ______________

PATIENT POSITION : _________________________________________________________________________________

NIL ORALLY : _______________________________ for hours thereafter _______________________________________

ANTI EIVIETICS : 1. __________________________________________________________________________________

2. __________________________________________________________________________________
3. __________________________________________________________________________________

ANTIBIOTICS : 1. ___________________________________________________________________________________
2. ___________________________________________________________________________________
3. ___________________________________________________________________________________

Instruction
ROUTINE CARE Y N
Continuous ECG Monitoring Y N
Continuous Pulse Oximeter Y N
BP Every 15 mins Y N
Sedation Score 15 mins Y N
Pain score 15 mins Y N

OXYGEN : _________________________________________________________________________________________
__________________________________________________________________________________________________

ANALGESIA :_______________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________

INTRAVENOUS FLUIDS : ______________________________________________________________________________

__________________________________________________________________________________________________

OTHER MEDICATIONS: _________________________________________

Recovery Room In Time
____________________________________________________________
____________________________________________________________
____________________________________________________________
Recovery Room Out Time
____________________________________________________________

ANY OTHER INSTRUCTIONS : ____________________________________

____________________________________________________________ Doctors Name & Sign
Date :
NOTES :
 PATIENT LABEL
Name : Age : Sex :
M/F
MRN : Bed No.
 MODIFIED ALDRETE SCORE

S.N POINT 30” 1 HOUR 2 HOUR

Activity
2
Move the 4 extremities voluntarily or to order
1 1
Moves two 2 extremities voluntarily or to order
0
Unable to move limbs

Breathing
2
Able to breathe deeply and cough freely
2 1
Dyspnoea or limited breathing
0
Apnea

Circulation
TA Difference less than or equal to 20% of 2
3 The pre-sedation level 1
Unlike TA 20% - 50 % pre-sedation level 0
TA difference greater than 50 % of the pre-sedation level

Awareness
2
Wide awake
4 1
Responds to call
0
No answer

02 Saturation
2
Superior to 92 % in room air
5 1
Need to keep O2 sat > 90 %
0
Less than 90 % with O2

Total Score :