Get Printable Anesthesia Record

The basic components of the anesthetic record sheet include patient-related data, preoperative assessment, provider information, anesthetics drugs and monitors, anesthetic techniques, perioperative vital signs, postoperative orders, and patient outcomes [[5], [6], [7], [8], [9], [10]].

In ance with the ASA Guidelines, “An anesthesiologist shall be responsible for determining the medical status of the patient and developing a plan of anesthesia care.” The Center for Medicare & Medicaid Services (CMS) requires that a medically directing anesthesiologist sign the pre-anesthesia documentation.

Patient interview to assess: Patient and procedure identification. Anticipated disposition. Medical history – includes patient's ability to give informed consent. Surgical History (PSHx) Anesthetic history. Current Medication List (preadmission and postadmission) Allergies/Adverse Drug Reaction (including reaction type)

The anesthesia record is a document that provides information about perioperative care. This provides data on preoperative assessment, anesthesia management, vital parameters, and intraoperative events.

1894. “Medical students E. Amory Codman (1869-1940) and Harvey Cushing (1869-1939)-develop the first anesthesia record using observed respiratory rate and palpated pulse rate.