[Dr. Eleanor Vance]
Consultant Anaesthetist
MBBS, FRCA
Practice Number: 1234567
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: City General 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: None known.
• Allergies: No known drug allergies.
• Social: Non-smoker, occasional alcohol consumption.
• Effort tolerance: Able to walk 100 meters without significant shortness of breath.
Examination:
• Airway:
- Fasting: 8 hours
- Mallampati score: Class I
- Mouth opening: 4 cm
- Neck mobility: Full range of motion.
- Teeth/ dentition: Dentures, upper and lower.
- Other airway concerns: None anticipated.
• Cardiovascular: Regular heart rate, no murmurs.
• Respiratory: Clear lung sounds bilaterally.
• Other: Nil.
Special investigations:
• Bedside: Nil.
• Laboratory: Hb 14.2 g/dL, Creatinine 88 umol/L, Na 140 mmol/L, K 4.1 mmol/L.
• Radiological: Chest X-ray clear.
• Other: Nil.
• Summary: Fit for surgery. Controlled hypertension. No significant anaesthetic risks identified.
• ASA classification: ASA II
• Concerns: Risk of post-operative pain.
• Anaesthetic plan: General anaesthesia with peripheral nerve block for post-operative analgesia.
2. INTRA-OPERATIVE ANAESTHESIA
General:
• Date of surgery: 1 November 2024
• Surgeon: Mr. David Jones
• Hospital: City General Hospital
• Anaesthetic start time: 09:00
• Anaesthetic end time: 12:00
• Total time: 3 hours
Intravenous lines, monitoring and other:
• Intravenous line: 18G in left forearm.
• Other lines (Central line/ Arterial line): Nil.
• Standard ASA Monitors applied (ECG, SpO2, NIBP, Capnography): Yes
• Other monitors: Temperature probe.
• Eyes taped shut: Yes
• Pressure points padded: Yes
• Warmer: Forced air warmer used.
• Calf compressors: Yes
Induction:
• Pre-oxygenation: 3 minutes with 100% oxygen.
• Drugs administered: Fentanyl 100 mcg, Propofol 150mg, Rocuronium 50mg.
• Airway management (NPO2, MASK, LMA, ETT): Endotracheal intubation, size 7.0 ETT.
• Positioning: Supine.
Maintenance:
• Anaesthetic technique (Sedation/ GA/ RA): General Anaesthesia
• Regional anaesthetic technique: Femoral nerve block performed.
• Ventilation: Volume-controlled ventilation, Vt 500ml, RR 12/min, FiO2 0.4.
• Drugs administered: Sevoflurane 1.5%, Rocuronium top-ups.
• Fluids administered: Hartmann's solution 1500ml.
• Blood loss: 300ml.
• Urine output: 200ml.
Emergence:
• Extubation: Awake and breathing spontaneously.
Intra-operative events:
• Complications/ interventions: Nil.
• Notes: Patient stable throughout the procedure.
3. POST-OPERATIVE CARE
Immediate recovery:
• Vital signs: BP 130/80 mmHg, HR 80 bpm, SpO2 98% on room air.
• Pain score: 3/10.
• Nausea/ Vomiting: Nil.
• Other complications: Nil.
Further care:
• Transfer (Back to ward/ ICU): Back to ward.
Ward prescription:
• Medication: Paracetamol 1g qds, Morphine 2.5mg PRN for pain, Ondansetron 4mg PRN for nausea, Enoxaparin 40mg daily.
Discharge prescription:
• Medication: As per ward prescription, to continue for 24 hours post-operatively. Review pain control and discharge with appropriate analgesia.
[Clinician full name]
[Clinician designation]
[Clinician credentials]
Practice Number: [Clinician practicing number]
PERI-OPERATIVE RECORD
1. PRE-OPERATIVE ASSESSMENT
Patient information:
• Name: [patient's full name] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
• Age: [patient's age] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
• Sex: [patient's sex] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
• Weight: [patient’s weight] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
• Height: [patient’s height] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
• Date of assessment: [date pre-op assessment was performed] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
• Procedure: [planned surgical procedure] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
• Surgeon: [name of operating surgeon] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
• Hospital: [name of hospital where procedure is to occur] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Medical history:
• Previous medical history: [relevant past or ongoing health conditions] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
• Medications: [current and recent medications including dosages and frequency] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
• Previous surgical history: [any significant surgeries patient has undergone] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
• Previous anaesthetic complications: [any prior issues with anaesthesia] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
• Allergies: [documented allergies including drug reactions] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
• Social: [relevant lifestyle and substance use information] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
• Effort tolerance: [level of physical activity the patient can perform without symptoms] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Examination:
• Airway:
- Fasting: [hours since last oral intake] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Mallampati score: [recorded airway classification] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Mouth opening: [mouth opening in cm or fingers] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Neck mobility: [range of movement of the neck] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Teeth/ dentition: [relevant dental or oral findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Other airway concerns: [any anticipated airway management difficulties] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
• Cardiovascular: [relevant cardiovascular examination findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
• Respiratory: [relevant respiratory examination findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
• Other: [other clinical findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Special investigations:
• Bedside: [results from point-of-care tests] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
• Laboratory: [lab investigation results] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
• Radiological: [radiology or imaging results] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
• Other: [other special investigations performed] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
• Summary: [summary of clinical findings and risks] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
• ASA classification: [ASA physical status] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
• Concerns: [specific perioperative concerns] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
• Anaesthetic plan: [intended anaesthetic technique and precautions] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
2. INTRA-OPERATIVE ANAESTHESIA
General:
• Date of surgery: [date operation occurred] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
• Surgeon: [operating surgeon’s name] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
• Hospital: [hospital name] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
• Anaesthetic start time: [time anaesthesia commenced] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
• Anaesthetic end time: [time anaesthesia concluded] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
• Total time: [total duration of anaesthesia] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Intravenous lines, monitoring and other:
• Intravenous line: [site and gauge of line inserted] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
• Other lines (Central line/ Arterial line): [other invasive access used] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
• Standard ASA Monitors applied (ECG, SpO2, NIBP, Capnography): [yes/no] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
• Other monitors: [additional monitoring modalities] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
• Eyes taped shut: [yes/no] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
• Pressure points padded: [yes/no] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
• Warmer: [warming measures applied] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
• Calf compressors: [DVT prophylaxis applied] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Induction:
• Pre-oxygenation: [method used and duration] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
• Drugs administered: [induction agents and doses] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
• Airway management (NPO2, MASK, LMA, ETT): [airway type and ease] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
• Positioning: [intraoperative positioning details] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Maintenance:
• Anaesthetic technique (Sedation/ GA/ RA): [anaesthesia type] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
• Regional anaesthetic technique: [nerve blocks or spinal/epidural details] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
• Ventilation: [mode and parameters] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
• Drugs administered: [maintenance agents used] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
• Fluids administered: [type and volume of fluids given] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
• Blood loss: [estimated volume] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
• Urine output: [recorded urine volume] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Emergence:
• Extubation: [method and condition of extubation] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Intra-operative events:
• Complications/ interventions: [any intraoperative events or corrective actions] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
• Notes: [other significant intraoperative information] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
3. POST-OPERATIVE CARE
Immediate recovery:
• Vital signs: [immediate post-op vitals] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
• Pain score: [post-op pain rating] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
• Nausea/ Vomiting: [presence and treatment] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
• Other complications: [any other recovery issues] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Further care:
• Transfer (Back to ward/ ICU): [destination post-recovery] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Ward prescription:
• Medication: [medications ordered for the ward] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Discharge prescription:
• Medication: [discharge medications and instructions] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
(Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes or clinical note as a reference for the information include in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or omit the placeholder completely.) (Use as many lines, paragraphs or bullet points, depending on the format, as needed to capture all the relevant information from the transcript.)
