Anaesthetist Template
ANAESTHETIC PERI-OPERATIVE RECORD
A professional Anaesthetist template for healthcare professionals.
About this template
Looking for a streamlined way to document anaesthetic procedures? This Anaesthetic Peri-Operative Record template is perfect for anaesthetists. It allows for comprehensive documentation of pre-operative assessments, intra-operative anaesthesia details, and post-operative care. This template ensures all critical information is captured, from patient history and examination findings to anaesthetic techniques and post-op recovery. Heidi can quickly populate this template, saving valuable time and improving the accuracy of your clinical notes.
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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.
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