ANAESTHETIC PERI-OPERATIVE RECORD

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.)