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Free Anesthesia Record PDF Template

The Anesthesia Record form serves as a comprehensive document used by healthcare professionals to track and record all the pertinent details related to anesthesia before, during, and after a medical procedure. It encompasses a wide array of information, including patient identification, medical history, the anesthesia process, and post-operative care instructions. This form plays a crucial role in ensuring the safety and effectiveness of anesthesia management and patient recovery.

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Outline

An Anesthesia Record form is an essential document that meticulously captures all the crucial details before, during, and after an anesthetic procedure. This form contains comprehensive sections, including the patient's name, ID, species, breed, age, weight, and the owner's information. It also describes the patient's medical history, physical examination findings, and the American Society of Anesthesiologists (ASA) classification, indicating the patient's health status before anesthesia. The form outlines the pre-anesthetic medication, including the doses, routes, and times administered, as well as detailed records of the anesthesia process itself such as induction agents used, patient positioning, breathing systems, patient warming, and the anesthesia safety checklist completion. The monitoring of vital signs such as heart rate, respiration rate, body temperature, and pain scores during recovery provides essential data for post-operative care. Additionally, it includes specific sections for anticipated problems, recovery concerns, instructions, and post-op care like IV catheter care, fluid therapy, and analgesia. Furthermore, graphical elements are often integrated to visually track the patient's heart rate, respiratory rate, and other critical parameters over time, providing an at-a-glance view of the patient's status throughout the anesthesia and recovery process. This form proves crucial for ensuring patient safety, facilitating communication among care teams, and serving as a legal document for the medical record.

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Anaesthesia & recovery record

Date:

Sheet no.:

Click here

to add logo

Name:

History:

Temperament:

ASA classification

Owner:

Patient ID:

HR:RR:

Pulse quality:

INo organic disease

IIMild systemic disease

Species:

Clinical findings/results/medications:

MM:

CRT:

Severe systemic disease

III

(not incapacitating)

Breed:

Age: Sex:

Weight:

Anaesthetist:

Clinician:

Thoracic auscultation:

Temperature:°C

Severe disease

(constant threat to life)

Moribund

(life expectancy < 24 h)

Add ‘E’ for emergencies

ASA Grade:

Procedure(s):

Anticipated problems:


Pre-GA medication	Dose	Route Time
………………………………………….	………………..	……….. ………...
……………………………………….…	………………..	……….. ………...
……………………………………….…	………………..	……….. ………...
……………………………………….…	………………..	……….. ………...

ET tube / LMA / Mask		Size:
Cuffed / Uncuffed

Anaesthetic

Safety

Checklist

completed

Eye(s)

lubricated


Induction agent(s)		Dose	Route	Time
……………………………………….…		………………..	………...	………...
……………………………………….…		………………..	………..	………...
……………………………………….…		………………..	………..	………...
IV catheter Position:			Size:


Breathing	Patient position:
Breathing
system:	Patient warming:
	Patient warming:

Anaesthesia monitoring record overleaf

Recovery concerns & instructions:

Temperature: °C

Extubation time:

IV catheter

care

Remove once recovered

Maintain & flush

Post-op fluid

therapy

Post-op

analgesia

Other

post-op

care

Relevant information transferred to kennel sheet / patient record

Monitoring during recovery

	T+0	T+15	T+30	T+45
Time
Time
Heart rate
Heart rate
Resp. rate
Resp. rate
MM & CRT
MM & CRT
Temp.
Temp.
Pain score
Pain score
Other
Other

		Time	Start procedure:				Finish procedure:
			Throat pack			Placed			Removed
		Notes	Throat pack			Placed			Removed
			volume	Total		……………..………ml				Dog
										Dog
				10%		……………..………ml			85ml/kg
				10%		……………..………ml

			Blood	20%		……………..………ml			Cat / Rabbit
									Cat / Rabbit
				30%		……………..………ml			55ml/kg
				30%		……………..………ml
			Notes


Key		240
Key		240
		230
HR	●

		220
	o	220
RR		210
RR		210
IPPV	ø	200
		200
		190
		190
SAP	˅	180
SAP	˅	180
MAP	–	170
		170
		160
		160
DAP	˄	150
		150
		140
Doppler		140
		130
		130
		120
Palpebral reflex

		110
Jaw tone		110
		100
		100
- / + / ++ / +++		90
		90
		80
		80
		70
Eye position

		60
		60
↓ / →		50
↓ / →		50
		40


		30
		30
		20
		20
		10
		10

Iso / Sevo		%

O2 / N2O / Air		L/min

Palpebral reflex			Swabs					Sharps

Eye position			In		Out			In		Out

Jaw tone

Pulse quality

ETCO2		kPa/mmHg

SpO2		%

Temperature		°C

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Document Attributes

Fact Name	Detail
Form Purpose	Documents anesthesia and recovery phases for patients.
Content Areas	Includes patient identification, history, clinical findings, and anesthesia details.
ASA Classification	Assesses the patient's pre-anesthesia medical risk using the American Society of Anesthesiologists (ASA) physical status classification system.
Anaesthetic Record	Records medications, dosages, routes, and times for anesthesia and pre-GA medication.
Anaesthetic Safety Checklist	A checklist to ensure all safety protocols are followed before anesthesia is administered.
Monitoring During Anesthesia	Details monitoring of heart rate, respiratory rate, blood pressure, and other vital parameters during anesthesia.
Recovery Concerns & Instructions	Outlines post-operation care including analgesia, fluid therapy, and monitoring during recovery.
Post-op Care	Includes instructions for extubation, IV catheter care, post-operative fluid therapy, analgesia, and other care requirements.
Visualization of Data	Utilizes symbols and shorthand for efficient recording and visualization of monitoring data.
Governing Laws	Practices in anesthesia documentation may be guided by state-specific veterinary medical board regulations. However, no specific laws are provided within this context.

How to Fill Out Anesthesia Record

Filling out an Anesthesia Record form is a structured process that demands attention to detail and an understanding of the medical and procedural information pertaining to the patient and the anesthesia administered. This form plays a critical role in ensuring that the anesthesia process, from pre-medication to recovery, is documented meticulously to provide continuous and comprehensive care. Follow these steps carefully to ensure the form is filled out correctly and completely.

Begin by entering the Date of the procedure and the Sheet number at the top of the form to maintain organized records.
Add the facility's logo by clicking on the "Click here to add logo" space, if applicable, to personalize and identify the form.
Fill in the patient's Name, Owner's details, and the Patient ID to ensure clear identification.
Document the patient’s History, including previous medical conditions, and describe the patient's Temperament to help anticipate and manage behavior during anesthesia.
Classify the patient’s preoperative status using the ASA classification and indicate the specific category next to ASA Grade.
Complete the section on the patient’s species, breed, age, sex, and weight as these factors can influence anesthesia protocols.
Record the names of the Anaesthetist and Clinician involved in the procedure to attribute responsibility and facilitate communication.
Under Clinical findings/results/medications, list any pertinent clinical observations, results from tests, and medications administered.
Specify the procedure(s) being performed in the Procedure(s) field and identify any Anticipated problems.
Detail the Pre-GA medication, including dose, route, and time administered, to ensure a cohesive anesthetic plan.
Note the size and whether the ET tube/LMA/Mask is cuffed or uncuffed, and confirm that the Anaesthetic Safety Checklist is completed.
For the Induction agent(s), record the dose, route, and time similar to the pre-GA medication section.
Input the details of the IV catheter, including its position and size, and document the Patient position, Breathing system used, and Patient warming measures.
On the back of the form, fill in the Anesthesia monitoring record, keeping an eye on the patient’s vitals and other specified indicators at the times indicated.
Document any Recovery concerns & instructions, including post-op fluid therapy, analgesia, and other care requirements, ensuring a smooth transition to postoperative recovery.

Once all sections of the Anesthesia Record form are completed, review the document for accuracy and completeness. This record serves as a vital piece of the patient's medical history and contributes to the ongoing health and well-being of the patient following anesthesia and surgery.

More About Anesthesia Record

What is an Anesthesia Record form?

An Anesthesia Record form is a detailed document used by veterinarians and anesthesiologists to note down all relevant information about the anesthesia administered before, during, and after a surgical procedure. This includes details about the patient such as their medical history, the medications given, specifics of the anesthesia process like induction agents and their dosages, and the patient’s recovery process.

Why is maintaining an Anesthesia Record important?

Maintaining an accurate Anesthesia Record is crucial for multiple reasons. It ensures continuity of care by providing a comprehensive overview of the patient's response to anesthesia, helps in the assessment of the anesthesia protocol's effectiveness, and improves the safety and quality of care. Additionally, it serves as a legal document that can be referenced in case of any complications or disputes.

What does ASA classification mean on the form?

The ASA classification stands for the American Society of Anesthesiologists' physical status classification system. It evaluates the fitness of a patient prior to surgery. Ranging from I to V, with an addition of 'E' for emergency cases, it helps in assessing the risk involved in the anesthesia process. For instance, I indicates a healthy patient with no organic disease, while V refers to a moribund patient who is not expected to survive without the surgery.

How is patient warming noted on the Anesthesia Record?

Patient warming is a critical aspect noted on the Anesthesia Record. It details the method and equipment used to maintain the patient's body temperature during the procedure. Keeping the patient warm helps in preventing hypothermia, which is a common risk during anesthesia due to impaired thermoregulation.

What information is included under the 'Anaesthesia monitoring record'?

The 'Anaesthesia monitoring record' section is designed to document vital signs and other relevant parameters throughout the anesthesia process. This typically includes the heart rate, respiratory rate, blood pressure, and body temperature at various times, along with pain scores and any additional observations critical for assessing the patient’s condition and response to anesthesia.

How are pre-GA medications recorded?

Pre-General Anesthesia (pre-GA) medications are recorded by noting the name of each medication, the dose administered, the route of administration (e.g., oral, IV, IM), and the time given. This part of the record is crucial for planning the anesthesia protocol and for future reference, to understand which premedications were effective or if any adverse reactions occurred.

What does the 'E' symbol stand for in ASA classification?

The 'E' symbol in the ASA classification stands for 'Emergency.' It's added to any of the ASA physical status levels (I-V) to indicate that the procedure needs to be performed urgently. An emergency ASA classification highlights the increased risk associated with administering anesthesia under less-than-ideal circumstances, often with limited time for preparation.

What role does the Anesthetist play according to the Anesthesia Record?

The Anesthetist is responsible for administering the anesthesia and monitoring the patient's physiological status throughout the procedure. This includes selecting appropriate anesthetic agents and methods, managing the patient's airway, and ensuring they remain stable and pain-free during surgery and into recovery. Their name is documented on the form for accountability and reference.

How is the anticipated problems section used?

The 'Anticipated problems' section is used to note any potential challenges or risks identified prior to administering anesthesia. This could include anything from the patient's specific health concerns that might affect anesthesia to technical difficulties that may be encountered based on the procedure's nature. Documenting anticipated problems helps in preparing for and mitigating these risks as much as possible.

What is the significance of documenting the extubation time?

Documenting the extubation time – the moment when the endotracheal tube is removed after anesthesia – is significant for several reasons. It helps in monitoring the patient’s recovery from anesthesia, ensuring that the airway has been successfully managed, and reducing the risk of complications associated with premature or delayed extubation. It's a critical timestamp that marks a major step in the patient's return to normal respiration and consciousness.

Common mistakes

When filling out the Anesthesia Record form, various mistakes can occur, which might impact the quality of care provided. Ensuring the form is completed accurately and comprehensively is crucial for the safety and well-being of the patient. Below are nine common mistakes:

Not checking the form for completeness: Leaving sections unfilled or partially filled can lead to a lack of critical information, which may impact patient care during and after anesthesia.
Incorrect patient information: Entering wrong details such as the patient ID, name, species, breed, age, or weight can lead to significant errors in anesthesia management and post-operative care.
Inaccurate recording of medical history and ASA classification: Failing to accurately assess and record the ASA (American Society of Anesthesiologists) classification and the patient’s medical history can result in inappropriate anesthesia plans.
Omitting to document pre-anesthesia medications: Not recording the drugs, doses, routes, and times of pre-anesthesia medications may affect patient monitoring and post-operative care.
Failure to complete the anaesthetic safety checklist: Skipping or incompletely filling out the safety checklist compromises patient safety.
Misrecording anesthesia induction and maintenance agents: Incorrectly documenting the agents, their doses, and the times administered can lead to errors in patient management.
Errors in documenting patient monitoring data: Incorrect or incomplete recording of monitoring data such as heart rate, respiratory rate, and temperature during anesthesia can affect patient outcomes.
Neglecting to record post-operative care instructions: Failing to provide clear recovery concerns, instructions, and post-operative care plans can lead to misunderstandings and inadequate patient care.
Forgetting to detail the procedure(s) performed: Not specifying the procedures done during anesthesia compromises the accuracy of the medical record and patient care.

In addition to these common mistakes, it's also important to:

Verify and double-check all information for accuracy.
Ensure that the form is updated in real-time to reflect any changes in the patient's condition or treatment plan.
Communicate clearly with the entire veterinary team to maintain a consistent and comprehensive understanding of the patient's status and care needs.

By avoiding these mistakes, the accuracy of the Anesthesia Record can be significantly improved, enhancing the safety and quality of care for the patient.

Documents used along the form

When managing anesthesia for patients, whether in a veterinary or human medical setting, an Anesthesia Record form is a crucial document. However, this form doesn't exist in isolation. Several other forms and documents are often used alongside it to ensure comprehensive care and accurate record-keeping. Each of these documents plays a specific role in the perioperative process, contributing to a safer and more effective treatment outcome.

Consent Forms: Before any anesthesia or procedure is performed, a signed consent form from the patient or, in the case of veterinary practice, the pet owner, is essential. This document outlines the risks and benefits of the procedure, ensuring that consent is informed and legally documented.
Pre-Anesthetic Evaluation Forms: These forms record the patient's medical history, physical examination findings, and any pre-existing conditions that could affect anesthesia. They help anesthesiologists tailor the anesthesia plan to each individual patient.
Medication Administration Record (MAR): The MAR tracks all medications given to the patient, including pre-anesthesia medications, induction agents, and any intraoperative drugs. This ensures any changes in patient status can be quickly addressed and accurately attributed to specific medications.
Surgical Safety Checklist: Championed by the World Health Organization, this checklist is used to enhance safety in the operating room. It covers critical safety checks before anesthesia is administered, before incision, and before the patient leaves the operating theater.
Anesthetic Safety Checklist: Similar to the surgical safety checklist, this focuses specifically on anesthesia equipment and practices, ensuring everything is properly prepared and functioning before anesthesia is administered.
Patient Monitoring Logs: Throughout the procedure, and into recovery, patient vital signs and anesthesia depth indicators are closely monitored and recorded. This ongoing log provides a clear, time-stamped record of patient status throughout the anesthesia process.
Pain Assessment and Management Records: Effective pain management is critical in both human and veterinary medicine. These records document pain assessments, any analgesics administered, and their efficacy, ensuring patient comfort and aiding in recovery.
Recovery Room Records: Post-anesthesia, patients are closely monitored until they meet specific criteria for returning to their hospital room or being discharged. These records document vital signs, awareness level, pain management, and any complications encountered.
Discharge Instructions: Before a patient leaves the hospital, clear instructions for home care, including pain management, activity levels, signs of complications, and follow-up appointments, are provided. These instructions ensure that the recovery process continues smoothly at home.

In summary, the Anesthesia Record form is a key piece of a larger puzzle. Together with consent forms, pre-anesthetic evaluations, medication tracking, safety checklists, monitoring logs, pain management records, recovery documentation, and discharge instructions, it forms a comprehensive network of information. This network not only enables high standards of care but also ensures safety and legal compliance throughout the perioperative process. Whether for human or veterinary patients, these documents collectively support a successful anesthesia experience and recovery.

Similar forms

The Anesthesia Record form is an essential document used in medical procedures involving anesthesia, meticulously recording every detail to ensure patient safety and effective anesthesia management. This form shares similarities with several other medical records due to its emphasis on tracking patient information, clinical findings, and treatment details. Below are six types of documents that bear resemblance to the Anesthesia Record form:

Medical History Record: Similar to the Anesthesia Record, the Medical History Record collects comprehensive information on a patient's medical background. It includes past and present medical conditions, allergies, and medications, which are critical for tailoring anesthesia and other treatments to the patient's specific health needs.
Surgical Consent Form: This document, like the Anesthesia Record, involves procedural preparation and informed consent. While the Surgical Consent Form is primarily focused on obtaining the patient's or guardian’s permission for surgery and explaining the risks, the Anesthesia Record also deals with preparation, but with a focus on anesthesia-specific details.
Pre-operative Checklist: The Anesthesia Record and the Pre-operative Checklist share the goal of ensuring that all necessary preparations have been made before a procedure begins. Both include checks on equipment, patient status, and procedural plans to minimize risks during surgery and anesthesia.
Post-operative Care Record: Post-operative Care Records detail the care and observations following a procedure, akin to the recovery section of the Anesthesia Record. Both documents are essential for tracking patient recovery, noting any complications, and outlining specific post-operative care instructions, including medications and monitoring requirements.
Patient Monitoring Form: During a procedure, continuous monitoring is crucial. The Patient Monitoring Form, like the Anesthesia Record, logs vital signs, fluid intake and output, and other parameters critical for assessing the patient's condition throughout the surgical and recovery processes.
Medication Administration Record (MAR): The MAR is closely related to sections of the Anesthesia Record that document pre-GA medications, induction agents, and other drugs administered. Both documents are vital for ensuring appropriate dosing, timing, and administration routes, contributing to safe and effective patient care.

Each of these documents plays a crucial role in the comprehensive care and management of patients undergoing medical procedures, emphasizing the importance of detailed record-keeping for safety, efficacy, and continuity of care.

Dos and Don'ts

When completing the Anesthesia Record form, following best practices is essential to ensure the accuracy and safety of the anesthesia process. Below are the do's and don'ts to consider.

Do:

Verify all patient information for accuracy, including Name, Patient ID, Species, Breed, Age, Sex, and Weight, to prevent any mishaps or confusion.
Fill in all sections comprehensively, ensuring that every field from the history and Temperament to the ASA Classification is completed to provide a clear medical picture.
Record all medication details precisely, including Pre-GA medication, Dose, Route, and Time, to ensure proper medication management and avoid adverse reactions.
Meticulously document the details of the anesthesia process, including Induction agent(s), ET tube/LMA/Mask Size, and Patient Warming, to maintain a high standard of care.
Monitor and record post-operative care instructions, noting any Recovery concerns & instructions and the specifics of Monitoring during recovery, to guarantee a safe and comfortable recovery period for the patient.

Don't:

Skip any details in the Anaesthetic Safety Checklist, as this could lead to critical oversight during the anesthesia process.
Omit any information regarding the patient's condition and monitoring data over time, including Temperature, Heart rate, Resp. rate, MM & CRT, and Pain score, which are vital for assessing the patient’s ongoing condition.
Ignore the importance of documenting the Overall procedure start and finish times, as well as any notes on Fluid therapy and Analgesia, which are crucial for post-operative care auditing and follow-ups.
Forget to indicate the size and type of IV catheter used, or to provide detailed Post-op care instructions, including IV catheter care and Post-op fluid therapy, to ensure continuity of care once the anesthesia wears off.
Overlook transferring Relevant information to the kennel sheet/patient record, which is essential for the next shift or caregivers to continue with appropriate care and monitoring.

Misconceptions

When it comes to Anesthesia Records, there's quite a bit of confusion about what they are and what information they should contain. Let's clear up some common misconceptions:

Anesthesia Records are only about documenting medications.
This is a common misconception. While documenting medications, their doses, and times of administration is crucial, Anesthesia Records encompass much more. They include patient identification, history, physical examination findings, details of the anesthesia process (including monitoring, equipment used, and patient response), and recovery information. This comprehensive approach ensures the entire process is safe and effective for the patient.
All patients have the same Anesthesia Record form.
Even though the basic structure of an Anesthesia Record might be similar—covering pre-anesthetic medication, induction, maintenance, and recovery—each patient's form is unique. Factors like the patient's health status (indicated by ASA classification), the specific procedure being performed, and anticipated problems or complexities tailor the Anesthesia Record to each case. This customization ensures each patient's needs are met appropriately.
Digital Anesthesia Records have replaced paper forms.
In today's digital age, many believe paper forms are obsolete. However, both paper-based and digital Anesthesia Records are in use. The choice depends on the veterinary practice's preference, the specific needs of the procedure, and sometimes, the complexity of the case. Digital records offer benefits like easy storage and retrieval, but paper forms still have their place in many practices for their simplicity and reliability in various situations.
Only the anaesthetist needs to read the Anesthesia Record.
Although the anaesthetist plays a critical role in filling out the Anesthesia Record, it's a mistake to think they are the only ones who need to review it. The entire medical team, including the clinician, nurses, and any specialists involved, should have access to and understand the Anesthesia Record. It ensures continuity of care and informs all team members about the patient's status and treatment plan.
Anesthesia Records are not important for post-op care.
The Anesthesia Record plays a vital role even after the surgical procedure is complete. It provides detailed information about the patient's response to anesthesia, any complications that occurred, and specific recovery instructions. This information is crucial for those overseeing the patient's post-operative care, ensuring they are aware of any concerns that may affect recovery. Additionally, details about post-op analgesia and any other special instructions are included to guide the care team in providing the best possible recovery environment for the patient.

Understanding the significance and comprehensive nature of Anesthesia Records can significantly impact patient care, making every phase from pre-op preparation to recovery safer and more effective.

Key takeaways

When it comes to the Anesthesia Record form, there are several key takeaways that are essential for ensuring the safety and effective management of anesthesia for patients. This form serves as a comprehensive document to track all relevant details before, during, and after an anesthetic procedure. Here are five critical insights into filling out and using this form:

Accurate and thorough documentation is critical. Every section of the Anesthesia Record form, from patient history to recovery instructions, must be filled out meticulously. This includes noting the patient’s ASA classification, which assesses the physical status and anesthetic risk, and recording all medications administered with their doses, routes, and times. This detailed record-keeping is vital for monitoring the patient’s response to anesthesia and for any future anesthetic events the patient may undergo.
The importance of the preoperative assessment. The form requires specific details about the patient's history, temperament, and clinical findings. This information, alongside the ASA classification, helps in formulating an anesthetic plan tailored to the patient’s needs and identifying any potential risks or concerns prior to anesthesia.
Monitoring during anesthesia is crucial. The Anesthesia Record form includes a section for monitoring vital signs and other critical parameters during the procedure. Regular recording of heart rate, respiratory rate, temperature, and other metrics provides real-time data that is essential for maintaining the patient’s stability during anesthesia.
Postoperative care and instructions are outlined for continuity of care. The section on recovery concerns and instructions is an integral part of the form, ensuring a smooth transition from anesthesia to recovery. This includes guidelines on extubation, IV catheter care, postoperative fluid therapy, analgesia, and other necessary post-op care. It also emphasizes the importance of transferring relevant information to the patient's kennel sheet or record for monitoring during recovery.
Use of the form facilitates communication among the veterinary team. By providing a detailed and structured record, the Anesthesia Record form serves as a critical tool for communication within the veterinary team. It ensures that every team member is aware of the patient's anesthetic management plan, can note any intraoperative adjustments, and is prepared for any anticipated problems, thereby enhancing the safety and efficacy of patient care.

In summary, the Anesthesia Record form is an indispensable tool in the management of anesthesia. It ensures comprehensive documentation, guides preoperative assessment and planning, facilitates intraoperative monitoring, outlines postoperative care, and enhances communication among the veterinary care team. Proper utilization of this form significantly contributes to the safety and success of anesthetic management.

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