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ANESTHETIC RECORD

Biochemistry HB
HCT
Pre-Operative Diagnosis Status

Name Room Consent Premedication: Date: Route: Time:

Age Sex Height Weight Temp. Poise Resp. B.P. Proposed Operation

HOURS

AGENTS

FLUIDS

37 37
BP X
36 240 36 240
PULSE O
35 220 35 220
RESP. O
34 200 34 200
TEMP. A
33 180 33 180
CVP. V
32 160 32 160

31 140 31 140

30 120 30 120

29 100 29 100

28 80 28 80

27 60 27 60
Chance
Canister
26 40 26 40
Suction
Suction
25 20 25 20
Recroom
R
SYMBOLS
ANESTHETIC AGENT DETAILED TECHNIQUE

OPERATION FLUID SUMMARY

URINE OUTPUT IN O.R.


ANESTHESIOLOGIST SURGEON DATE CONDOTION OF PATIENT IN DEPARTURE

SCRUB NURSE CIRCULATING NURSE

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