ANAESTHETIC PERI-OPERATIVE RECORD
1. PRE-OPERATIVE ASSESSMENT
Patient information:
Name: John Smith
Age: 68
Sex: Male
Weight: 85 kg
Height: 178 cm
Date of assessment: 1 November 2024
Procedure: Right Total Hip Replacement
Surgeon: Mr. David Jones
Hospital: St. Thomas' Hospital
Medical history:
Previous medical history: Hypertension, controlled with medication. Mild osteoarthritis.
Medications: Lisinopril 20mg daily, Paracetamol as needed.
Previous surgical history: Appendectomy 20 years ago.
Previous anaesthetic complications: Nil known.
Allergies: Penicillin.
Social history: Non-smoker, occasional alcohol consumption.
Effort tolerance: Able to walk 200m on flat ground.
Examination:
Airway findings: Mallampati score II.
Fasting status: Nil by mouth for 8 hours.
Mouth opening: Adequate.
Neck mobility: Full range of motion.
Teeth/dentition: Good dentition, no loose teeth.
Cardiovascular findings: BP 130/80 mmHg, regular heart rate.
Respiratory findings: Clear chest auscultation.
Special investigations:
Laboratory tests: Full blood count, urea and electrolytes, coagulation screen within normal limits.
Radiological tests: Chest X-ray clear.
Summary: Fit for surgery.
ASA classification: ASA II.
Concerns: Potential for post-operative pain.
Anaesthetic plan: General anaesthesia with regional block.
2. INTRA-OPERATIVE ANAESTHESIA
General:
Date of surgery: 1 November 2024
Surgeon: Mr. David Jones
Hospital: St. Thomas' Hospital
Anaesthetic start time: 09:00
Anaesthetic end time: 12:00
Total time – calculated from start and end times: 3 hours
Intravenous lines, monitoring and other:
Intravenous line: 18G in left arm.
Other lines (central/arterial): Nil.
Standard ASA monitors applied (ECG, SpO2, NIBP, Capnography): Yes.
Other monitors: Bispectral index (BIS).
Eyes taped shut: Yes.
Pressure points padded: Yes.
Warmer used: Yes.
Calf compressors: Yes.
Induction:
Pre-oxygenation: 3 minutes.
Drugs administered: Fentanyl 100mcg, Propofol 200mg, Rocuronium 50mg.
Airway management (NPO2, Mask, LMA, ETT): Endotracheal tube.
Positioning: Supine.
Maintenance:
Anaesthetic technique (Sedation/GA/RA): General Anaesthesia.
Regional anaesthetic technique: Femoral nerve block.
Ventilation: Controlled ventilation.
Drugs administered: Isoflurane, Rocuronium.
Fluids administered: Hartmann's solution 1000ml.
Blood loss: 300ml.
Urine output: 400ml.
Emergence:
Extubation: Awake and responsive.
Intra-operative events:
Complications/interventions: Nil.
Notes: Patient stable throughout procedure.
3. POST-OPERATIVE CARE
Immediate recovery:
Vital signs: Stable, BP 120/70 mmHg, HR 70 bpm, SpO2 98% on room air.
Pain score: 3/10.
Nausea/vomiting: Nil.
Further care:
Transfer (back to ward/ICU): Back to ward.
Ward prescription:
Medication: Paracetamol 1g qds, Morphine 2.5mg PRN for pain.
Discharge prescription:
Medication: Paracetamol 1g qds for 7 days, review with GP in 2 weeks.
ANAESTHETIC PERI-OPERATIVE RECORD
1. PRE-OPERATIVE ASSESSMENT
Patient information:
[Name] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
[Age] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
[Sex] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
[Weight] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
[Height] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
[Date of assessment] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
[Procedure] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
[Surgeon] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
[Hospital] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Medical history:
[Previous medical history] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
[Medications] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
[Previous surgical history] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
[Previous anaesthetic complications] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
[Allergies] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
[Social history] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
[Effort tolerance] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Examination:
[Airway findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
[Fasting status] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
[Mallampati score] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
[Mouth opening] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
[Neck mobility] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
[Teeth/dentition] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
[Other airway concerns] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
[Cardiovascular findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
[Respiratory findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
[Other examination findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Special investigations:
[Bedside tests] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
[Laboratory tests] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
[Radiological tests] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
[Other investigations] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
[Summary] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
[ASA classification] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
[Concerns] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
[Anaesthetic plan] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
2. INTRA-OPERATIVE ANAESTHESIA
General:
[Date of surgery] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
[Surgeon] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
[Hospital] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
[Anaesthetic start time] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
[Anaesthetic end time] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
[Total time – calculated from start and end times] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Intravenous lines, monitoring and other:
[Intravenous line] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
[Other lines (central/arterial)] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
[Standard ASA monitors applied (ECG, SpO2, NIBP, Capnography)] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
[Other monitors] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
[Eyes taped shut] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
[Pressure points padded] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
[Warmer used] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
[Calf compressors] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Induction:
[Pre-oxygenation] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
[Drugs administered] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
[Airway management (NPO2, Mask, LMA, ETT)] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
[Positioning] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Maintenance:
[Anaesthetic technique (Sedation/GA/RA)] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
[Regional anaesthetic technique] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
[Ventilation] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
[Drugs administered] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
[Fluids administered] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
[Blood loss] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
[Urine output] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Emergence:
[Extubation] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Intra-operative events:
[Complications/interventions] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
[Notes] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
3. POST-OPERATIVE CARE
Immediate recovery:
[Vital signs] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
[Pain score] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
[Nausea/vomiting] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
[Other complications] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Further care:
[Transfer (back to ward/ICU)] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Ward prescription:
[Medication] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Discharge prescription:
[Medication] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
(For each section, only include if explicitly mentioned in transcript or contextual notes, else omit section entirely. Never come up with your own patient details, assessment, plan, interventions, evaluation, or next steps—use only the transcript, contextual notes, or clinical note as reference for all information. If any information related to a placeholder has not been explicitly mentioned, do not state that in the output; simply leave the relevant placeholder or section out entirely. Use as many lines, paragraphs, or bullet points as needed to capture all relevant information from the transcript.)
