Anesthesia Record (Perioperative)

Anesthesia Record (Perioperative)

(Use this template to document narrative elements that supplement the time-based flowsheet for general anesthesia, regional anesthesia, or monitored anesthesia care [MAC]. Do not use for moderate sedation outside anesthesia services.)

Documentation Principles

• (Chart contemporaneously; late entries must include both the actual event time and the documentation time.)
• (Every medication and fluid must be traceable to agent, dose, route, time, and person administering.)
• (Record physiologic data, medications, and fluids in structured flowsheet fields; use narrative sections below for interpretation, decision-making, and complications.)
• (If a required element cannot be obtained, document "Unable to assess/obtain" with the reason.)

Case Header

Patient: [Name]; [MRN]; [DOB / Age]; [Sex]; [Weight (kg)]; [Height (cm)]

Date of Service: [Date]

Location: [Facility]; [OR/Suite]; [Room]

Procedure: [Procedure name(s)]; [Laterality]; [Surgeon/Proceduralist]

Anesthetic Type: [General / Regional / MAC]

Anesthesia Team: [Attending]; [CRNA/AA]; [Resident/Fellow if applicable]

Anesthesia Start Time: [Time] | Anesthesia End Time: [Time]

(Include isolation precautions, pregnancy status, or implant/device alerts only if clinically relevant.)

Preanesthesia Evaluation

(Must be performed and documented within 48 hours prior to the procedure per CMS requirements.)

Verification and Readiness

• [Patient identity confirmed: yes / no] (State method if required.)
• [Procedure and laterality confirmed: yes / no]
• [Consent obtained / Emergency exception with rationale]
• [Planned disposition: PACU then home / PACU then floor / PACU then ICU / direct to ICU / other]
• [NPO status and last intake times]
• [Advance directives or perioperative code status plan] (Include only for high-risk cases when relevant.)

History and Risk-Relevant Review

• [Cardiac history and functional status]
• [Pulmonary history including OSA screening/diagnosis]
• [Neurologic history]
• [Renal/hepatic history]
• [Endocrine/metabolic history]
• [Bleeding risk, anticoagulants, antiplatelets with timing of last dose]
• [Prior anesthetic history and complications] (Include difficult airway, PONV, malignant hyperthermia, awareness.)
• [Relevant medications] (Include home opioids, beta blockers, anticoagulants, GLP-1 agents per local policy.)
• [Allergies with reaction type]
• [Pertinent diagnostics reviewed and relevant consults]

Focused Physical Examination

• [Vital signs or most recent values]
• [General appearance]
• [Airway assessment] (Include anticipated difficulty, dentition risks, Mallampati if used, mouth opening, neck mobility.)
• [Cardiovascular exam findings]
• [Pulmonary exam findings]
• [Targeted exam relevant to planned regional technique] (Only if applicable.)

Risk Assessment and Problem List

• ASA Physical Status: [I / II / III / IV / V] [E if emergency]
• [Key anesthesia problems] (e.g., aspiration risk, anticipated difficult airway, OSA with post-op monitoring plan, hemodynamic instability risk, regional contraindications.)

Anesthetic Plan

• [Planned technique: induction, maintenance, airway plan]
• [Monitoring escalation plan] (e.g., arterial line, central access.)
• [Vasoactive strategy]
• [Postoperative pain plan] (Include multimodal approach and planned regional blocks.)
• [PONV prophylaxis plan]
• [Special considerations] (Include positioning risks, tourniquet, one-lung ventilation, anticipated blood loss, neurologic monitoring as applicable.)

Preanesthesia Assessment Summary

[Narrative summary stating ASA PS, key risks, planned anesthetic technique, contingency plans, and confirmation of informed consent discussion] (If history or exam limited due to urgency, state what was attempted, why incomplete, and risk-mitigation plan.)

Pre-Procedure Safety Checks

• [Interval changes since preanesthesia assessment: none / updated findings]
• [Monitoring available and alarms set: verified / not applicable / unable with reason]
• [Suction, oxygen, airway equipment, emergency medications immediately available: verified / unable with reason]
• [Anesthesia machine checkout per local policy: verified / not applicable / unable with reason]
• [Pregnancy test if required: result / not indicated]
• [Anticipated critical events discussed during briefing] (List as applicable: hemorrhage risk, difficult airway, hemodynamic concerns, positioning.)

Intraoperative Anesthesia Record

(Use structured flowsheet for vital signs at least every 5 minutes, continuous pulse oximetry, and capnography for advanced airways. Use narrative elements below to document key decisions, events, and complications.)

Key Timestamps

• Anesthesia Start: [Time]
• Airway Secured: [Time] (Only if applicable.)
• Extubation/LMA Removal: [Time] (Only if applicable.)
• Anesthesia End: [Time]
• Transfer to Recovery: [Time]

Airway Management

(Include only if airway intervention beyond facemask was performed.)

• [Device type: ETT / LMA / SGA]; [Size]; [Depth]; [Cuff status]
• [Confirmation method: ETCO2 / auscultation / fiberoptic / other]
• [Laryngoscopy method: direct / video / fiberoptic]; [View grade]; [Number of attempts]; [Adjuncts used]
• [Airway complications] (e.g., difficult mask ventilation, dental injury, laryngospasm, bronchospasm, esophageal intubation.)

(For airway difficulty or adverse events, document time-stamped event notes: trigger and time, objective data, interventions with doses and times, response and outcome.)

Vascular Access and Invasive Monitoring

(Include only when obtained.)

• [Line type: PIV / Arterial / Central / IO]; [Site and laterality]; [Catheter size]; [Sterile technique: yes / no]; [Ultrasound guidance: yes / no]; [Complications]
• (Repeat for each line placed.)

Regional/Neuraxial Anesthesia

(Include only when performed.)

• [Block type]; [Laterality]; [Approach]; [Technique: single-shot / catheter]; [Guidance: ultrasound / landmark / nerve stimulator]
• [Local anesthetic: agent, concentration, volume]; [Adjuncts and doses]
• [Neuraxial details if applicable: level, needle type/gauge, catheter depth, test dose, sensory level achieved, motor block assessment]
• [Anticoagulation considerations per local policy]
• [Block success and complications]

Medications and Fluids

(Ensure structured MAR entries include drug, dose, route, time, and administering provider. For infusions, document start/stop times and rate changes. For PRN medications, include indication.)

• [Induction and maintenance agents]
• [Opioids, NMBAs, reversal agents, vasoactives, antibiotics, antiemetics, adjuncts]
• [Crystalloid and colloid totals]; [Blood products with type and volume]; [Estimated blood loss]; [Urine output if measured]

Positioning

• [Position(s): supine / prone / lateral / lithotomy / beach chair / Trendelenburg]
• [Pressure point protection and eye protection measures]
• [High-risk position precautions] (Include hemodynamic or neurologic precautions as relevant.)

Complications and Significant Events

(Document as time-stamped narrative event notes. If no significant events occurred, this section may be omitted or state "No intraoperative complications.")

• [Event description and time]
• [Objective data: SpO2, ETCO2, BP, HR, rhythm]
• [Suspected cause if known]
• [Interventions with doses and times]
• [Response and outcome]

(If standard ASA monitoring is omitted due to extenuating circumstances, explicitly document the reason.)

Emergence and Transfer

• Airway Status: [Extubated / LMA removed / Remained intubated]; [Oxygen device and settings]; [Ventilation adequacy]
• Mental Status: [Level of consciousness]; [Pain status]
• Hemodynamics: [Stability]; [Ongoing vasoactive support: yes / no]
• Lines/Drains/Catheters: [Items retained]; [Infusions ongoing]; [Regional catheter settings if applicable]
• Key Issues for Recovery Team: [Intraoperative events and anticipated concerns]
• Destination: [PACU / ICU / step-down / other] (Include reason if bypassing PACU.)

Transfer Summary: [Concise paragraph: fluids in/out, EBL, hemodynamic course, analgesia/regional details, PONV prophylaxis, precautions, handoff completed with receiving clinician]

Postanesthesia Evaluation

(Must be completed within 48 hours after the procedure per CMS requirements; the clock starts upon entry to recovery area.)

Required Assessment Elements

• Respiratory: [Rate, airway patency, oxygen saturation, adequacy]
• Cardiovascular: [HR, BP, stability]
• Mental Status: [Level of consciousness, orientation]
• Temperature: [Value]
• Pain: [Assessment and adequacy of management]
• Nausea/Vomiting: [Present / absent; treatment if given]
• Hydration: [Status]

Additional Elements

(Include when relevant.)

• [Anesthesia-related complaints: sore throat, awareness concern, dental injury, other]
• [Neuromuscular recovery if NMBAs used]
• [Disposition and ongoing monitoring needs: OSA precautions, ICU requirements]
• [If patient cannot participate in evaluation: document reason and expected recovery trajectory]

Discharge Authorization: [Authorized by name/role and time / Criteria-based discharge per protocol] (If PACU bypassed, document bypass criteria and receiving unit's capability for postanesthesia care.)