ANESTHESIA

DPOTMH-OR-F001 RECORD
Unauthorized duplication of this form is strictly prohibited
NAME OF PATIENT (SURNAME, FIRST NAME, MIDDLE INITIAL) AGE SEX RELIGION HEIGHT WEIGHT DATE OF BIRTH ROOM NUMBER HOSPITAL NUMBER

PREOPERATIVE DIAGNOSIS BP HR RR NPO PERTINENT PREINDUCTION EVALUATION

PROPOSED OPERATION ASA CLASSIFICATION

PREOPERATIVE MEDICATIONS

HOURS AM/PM
AGENTS O2

FLUIDS

MONITORS

240

220

200

˅ SBP
˄ DBP 180

RESPIRATION
O SPONTANEOUS 160
Ø ASSISTED
● CONTROLLED
140
ANESTHESIA
X START
END 120

SURGERY
ꙨSTART 100
ꝊEND

Τ INTUBATION 80
ꓕ EXTUBATION

60

40

20

URINE OUTPUT (mL)

BLOOD LOSS (mL)

SYMBOLS

POSITION
ANESTHETIC AGENT TECHNIQUE

MEDICATIONS

OPERATION DONE EMERGENCE AND REMARKS TOTAL FLUIDS:

TOTAL BLOOD LOSS:

POST-OPERATIVE DIAGNOSIS
TOTAL URINE OUTPUT:

ANESTHESIOLOGIST SURGEON DATE