Start Time/ Room/Length

Phone Number……………………

Name / MRN / Surgery / Diagnosis: / Surgeon / Start Time/ Room/Length
Age / Sex / Attending: / H: W: BMI:

Temp BP BP Normally: RR: O2:

PMH (rank from most severe to least)
: severity / duration / treatment
: heavy tobacco / EtOH /Drug?
: Snoring?
: Reflux? / PSH
: anesthesia used
: complications
h/o Anesthesia:
PONV
Difficult Airway
Intubation
Anaphylaxis
Failed intubation
GRADE
BLADE
Allergies:
Anaphylaxis and airway swelling vs side effects / Labs/Studies:
Vitals: (see above)
Exercise Tolerance: Poor/Mod /Extreme
ROS: (see below)
Time last ate:
Airway Exam:
: MP
: TM dist:
: C Spine F/E
: Oral opening:
: Dentition:
: Beard
: Mand size
: Overbite:
: XRT / Tumor:
Exam Other:
: CV: irregular pulse, arrhythmia, S1, S2, S3, S4, PMI
: Pulm: CTAB, wheezes, rales/rhochi
: Abdomen: edema, burns
: IV (___ G , ____ location)
PTT CXR:
PT/INR:
Mg:
Phos:
AST/ALT:
A1c:
EKG/Echo/PFT/Carotid/: / Anesthetic Plan:
ASA status: (see below)
IV access:
Blood products (____ T&Crossed, ____ EBL)
Premedications (anxiolytics, BP, BG)
Abx:
Positioning:
Intraop monitoring (ABG, EEG, CVP)
Fluids: / Anesthetic Plan:
Induction (Meds , Airway: ETT ______, Mac/Miller)
Maintenance (meds, gtts, key surgical events!)
Emergence (light vs deep, which stage?)
Post op:
: PONV: Apfel Score: ____ ,
: Pain:
: HD:
Dispo: