Patient: _________________________ SEDATION AND ANESTHESIA RECORD

ID#: __________________________
DATE AGE ASA NPO Surgeon Anesthetist
J Premed ___________________________________
1 2 3
J Equipment check
WEIGHT HT BMI AIRWAY Surgical Asst. Anesthesia Asst.
J Time Out
Mallampati
PREOPERATIVE START TIME: 1 2 3 4
AGENTS/DRUGS 0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 TOTALS
MIDAZOLAM mg
FENTANYL 50 mcg/mL mcg
PROPOFOL 10 mg/mL mg
METHOHEXITAL 10 mg/mL mg
KETAMINE mg
DEXAMETHASONE 4 mg/mL mg
mg
mg
LIDOCAINE 2% 1:100K epi mL
ARTICAINE 4% 1:100K/200K epi mL
BUPIVACAINE .5% 1:200K epi mL
MEPIVACAINE 3% mL
PRILOCAINE 4% 1:200K epi mL
FLUIDS NS LR mL
NITROUS OXIDE L/min %
OXYGEN L/min %

0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75
MONITORS ECG IV
SpO2
J AUTO BP R L J 22G Catheter x__
mmHg
J ECG (Lead II) BIS J 20G Catheter x__
J PULSE OXIMETER TEMP J __________ x__
J STETHOSCOPE 200 R J Antecubital x__
J CAPNOGRAPH L J Radial x__
180
J BIS J Dorsum hand x__
J TEMP 160 R J __________ x__
SYMBOLS AIRWAY
140
SBP V J Nasal Cannula
V
DBP 120 J Nasal Mask
PULSE • J Mask
RESP ❍ 100 J Nasopharyngeal
J Oral
Anes X (Start)
80 J LMA
Anes _X (Stop)
J ET Tube
Surg ❍. (Start) 60
Surg _. (Stop)
❍
40
POSITION
J RECLINED 20
J SUPINE
0

DX:
TX:
REMARKS:____________________________________________________________________________________________________________
Dr. SIGNATURE: ___________________________________________
 POST ANESTHESIA CARE AND DISCHARGE RECORD

Patient: ________________________________________ ID#: _____________________________________

ARRIVAL TIME:
AGENTS/DRUGS 0 5 10 15 20 25 30 35 40 45 50 55 60 TOTALS

FLUIDS NS LR mL
OXYGEN L/min %
ECG
SpO2 IV
200
MONITORS J 22G Catheter
J AUTO BP R L 180 J 20G Catheter
J ECG (Lead II) J ___________
J PULSE OXIMETER 160
R J Antecubital
SYMBOLS 140 L J Radial
SBP V J Dorsum hand
V 120 J N/A
DBP
PULSE • 100 AIRWAY
RESP ❍
J Nasal Cannula
POSITION 80 J Nasal Mask
J RECLINED J Mask
60 J Nasopharyngeal
J SUPINE J Oral
40 J LMA
J N/A
20

Discharge Criteria
J Normal depth/rate of respiration (2)
J Moves 4 extremities at will (2)
J Alert and oriented x 3 (2)
J BP +/- 20% preop (2)
J None or mild nausea w/ no vomiting (2)
J Limited breathing/airway (1)
J Able to sit, but not stand (1)
J Aroused by verbal stimulus (1)
J BP +/- 21-40% preop (1)
J Transient vomiting or retching (1)
J Airway support needed (0)
J Non-ambulatory (0)
J Aroused by physical stimulus (0)
J BP > 40% preop (0)
J Persistent nausea and vomiting (0)

TOTAL SCORE = _____ [Patient may be discharged if total score is 8 or higher]

Discharge Vital Signs BP ________/________ HR_________

Disposition
Verbal instructions given to J Patient J Escort Written instructions given to J Patient J Escort

Name of individual accompanying patient ___________________________________ Relationship ____________________________

Discharge to J Home J Other: _________________________________________________________

Post-operative appointment J PRN J One week J 10-14 days J ___________________J Confirmed by scheduling staff

Person Discharging Patient ________________________________Person Taking Patient to Vehicle__________________________

Dr. Signature _____________________________________

 EMERGENCY RECORD

Patient:___________________________________________________ ID#: ____________________________

Doctor: _________________________________ Staff: _____________________________ Date: ____________

START TIME:
AGENTS/DRUGS 0 5 10 15 20 25 30 35 40 45 50 55 60 TOTALS
mg
mg
M mg
LIDOCAINE 2% 1:100K mg
ARTICAINE 4% 1:100K/200K mg
BUPIVACAINE .5% 1:200K mg
MEPIVACAINE 3% mg
PRILOCAINE 4% 1:200K mL
FLUIDS NS LR mL
NITROUS OXIDE L/min
OXYGEN L/min
ECG IV
SpO2
MONITORS J 22G Catheter x___
mmHg
J 20G Catheter x___
J AUTO BP R L 200
J __________ x___
J ECG (Lead II)
180 J ___G IO Tibia x___
J PULSE OXIMETER
R J Antecubital x___
J STETHOSCOPE 160
J CAPNOGRAPH L J Radial x___
J Dorsum hand x___
J AED 140

SYMBOLS 120 AIRWAY

SBP V J Nasal Cannula
V 100
DBP J Nasal Mask
PULSE • J Mask
80 J LMA
RESP ❍ J Nasopharyngeal
AED J Oral
* 60
J King
POSITION J ET Tube
40
J RECLINED
J SUPINE 20
J TRENDELENBERG
0

J 911 CALLED AT: _____________________ CALLER:_______________________________________________________________________

HISTORY OF EVENT: __________________________________________________________________________________________________
BRIEF MEDICAL HISTORY: ______________________________________________________________________________________________
MEDICATIONS:____________________________________________________________________ALLERGIES: _________________________
REMARKS/DISPOSITION: _______________________________________________________________________________________________
Dr. SIGNATURE: _________________________________________RECORDER SIGNATURE: ________________________________________

NOTE: COPY FOR EMS