PRE ANAESTHESIA NOTE

Name:………………………………………………………………………………..…AGE/SEX:……………………………………………………………….……………
ADDERSS……………………………………………………………………….REG.NO.:……………………...…………………………………………………………….
Provisional Diagnosis:………………………………………………………………….………………………………………………………………………………………

Proposed Surgery/Procedure:……………………………………………………………………………………………………………………………………………

History of Presenting illness:………………………………………………………………………………………………………………………………………………

Past medical history:-

(i) Diabetes –

(ll) hypertension

(ii) Thyroid –

(iii) Chest pain –

(iv) Exerton on dyspnea –

(v) Palpitations –

(vii) Epilepsy –

(viii) Bronchial asthma –

Past Surgical History –

Addiction-

Bowel/bladder habits-

Present/past medication of significance-

Allergy-

Any other past hospital admission-

Blood transfusions, if any-

Examination –

General –

(i) Consciousness –

(ii) Orientation –

(iii) P-

(iv) BP-

(v) SpO2-

(vi) RR –

(vii) Pallor –
 (viii) Icterus –

(ix) Cyanosis –

(x) Lymphadenopathy –

(xi) Edema –

Systemic-

(i) CNS –

(ii) CVS –

(iii) RS –

(iv) P/A –

ORAL / SPINE-

(i)Teeth –

(ii) Mouth opening –

(iii) MPC –

(iv) Neck –

(v) Spine –

Investigation –

(i) CBC –

(ii) LFT –

(iii) RFT –

(iv) BSL-R –

(v) CXR –

(vi) ECG –

(vii) HIV, HCV, HBsAG

(viii) Special –

Advice:-

Anaesthesiogist name
……….. ANESTHESIA NOTE

Date –

Name – Age Sex

Ward& bed –

Diagnosis –

Surgery/Procedure – Surgeon’s Name –

Assistant’s Name –

OT Staff –

Pre op advice and were they followed?

Consent -

Patient Relative

IV LINE - RVL LUL

RLL LLL

Pre check of Anesthesia Machine –

TYPES OF ANESTHESIA

(If spinal anesthesia is given, then please cancel out steps of general anesthesia)

Premedication –

Pre Oxygenation -

Induction -

Intubation -

Maintenance –

Spinal Anesthesia – Pt given sitting / lateral position AAP, P&D done, L3-4 space palpated & confirmed. Lumbar puncture
done using spinal needle …………………., free clear CSF-fluid aspirated. ……………. ml of Bupivacaine 0.5% (H)/ Lignocain 5
%( H) Injected +………….ml ………………. drug as an additive.

Monitoring chart

(Intra operative)

Time P BP SPO2 Block Level IVF Others

REVERSAL –

EXTUBATION –
PT Stifled to PACU –

Postop orders-\ (PACU)

Monitoring chart

(PACU)

Time P BP SPO2 Block Level IVF Others

WARD ORDERS:-
 Anesthesiologist
Name:

Date:- …./…../……….

I.P.D FIRST RECORD

OPD CASUALTY

Name:……………………………………………………………………………………AGE/SEX:…………………………………………………………………………...
ADDERSS……………………………………………………………………………………………………….REG.NO.:….…………………………………………………

History of presenting Illness : ……………………………………………………………………………………………………..……………………………………..

……………………………………………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………………………………………

Past medical history:-

(i) Diabetes – (v) Palpitations –

(ii) Thyroid – (vi) Heart cause –

(iii) Chest pain – (vii) Epilepsy –

(iv) Exertion on dyspnea – (viii) Bronchial asthma –

Obstrtric History –

Past Surgical History –

Addiction-

Bowel/bladder habits-

Present/past medication of significance-

Allergy-

Any other past hospital admission-

Blood transfusions, if any-

Examination –

General –

(i) Conscious – (vii) Pallor –

(ii) Orientation – (viii) Icterus –

(iii) P- (ix) Cyanosis –

(iv) SPO2 - (x) Lymphadenopathy –

(v) BP – (xi) Edema –

(vi) RR – (xii) T-

Systemic-
 (i) CNS – (ii) CVS –

(iii) RS – (iv) P/A –

(v) P/V – (vi) P/S –

Investigation –

(i) CBC – (ii) LFT –

(iii) RFT – (iv) BSL-R –

(v) CXR – (vi) ECG –

(vii) HIV, HCV, HBSAG (viii) Special –

Provisional Diagnosis:…………………………………………………………………………………………………………………………………..…………………….

Purpose Surgery:……………………………………………………………………………………………………………………………………………….……………….

ADMIT TO:-

Advice:-

Investigation Drug Orders, Diet etc IV Flluids

DUTY DOCTOR SIGNATURE

 Operative Note
Name:…………………........Age/Sex:……………..Reg.no.: …………
Surgery Performed:……….…………………………………………………
Anesthesia:…………………………………………………..…………………..
Anesthesiologist:…………………………………………………………………………
Surgeon name:…………………………………………………………………………
Note:-

Surgeons Signature
 Surgeons Name

Advice:-

Investigations Orders