Anesthesia log 2007

12345678-12

Patient information
Status

Ward

Patient no.

Age

Patient label

(Please adhere to the duplicate!)

out-patient
Please adhere this in the upper left corner!

hospitalized
day hospital Height (cm)

Weight (kg)

child

Gender

private

First name / Last name

male

infant < 12 months

female

newborn < 30 days

Date of birth

Department
General surgery

Gynecology

Cardiothoracic

Neurology

Accident surgery

Ear-Nose-Throat

Oral medicine

Radiology

Vascular surgery

Urology

Dermatology

Neuroradiology

Plastic surgery

Opthamology

Pediatrics

Nucleara medicine

Neurosurgery

Orthopedics

Psychiatry

Other

Pediatric surgery

Internal medicine

Ane. / ICU / Emerg.

Unknown

Street address

City, State, Zip

Insurance provider

Preoperative condition
Organ function
0

0 = cannot be determined, no information

Dental chant
1 = no pathological findings
normal
2 = path. findings not clinically relevant to procedure / anesth.
dentures
fillings
3 = path. findings clinically relevant to procedure / anesth.
Consciousness
Neurology
Musculature
Smoker

Pharynx Mallampati
at risk
needs
treatment

ACE inhibitor
Antihypertension
CA antagonist
Nitrates
Digoxin
-Blocker
Antiarrhythmics
Diuretics
Antiasthmatics
Corticoid

HF
ECG
Blood pressure
Myocardium
Coronary funct. RR
Vascular syst.

Lungs / Air passages

Chest x-ray
BGA / SB-H
Liver
Coagulation
Kidney
Metabolism
Electrolyte
Hematology

Krea

Thromb.

Hb

Quick

PTT

Coumarin
Aspirin
Heparin
Oral antidiabetics
Insulin
Other
Drugs
Nicotine
Alcohol
Antibiotics

Nutritional condition
Gastro-intestinal tract
Allergy
Anatomy
Diagnosis:

Procedure:

Important
findings / risks
Shock
Polytrauma
Drugged
ICU-patient
Untreated hypertension
Heart failure
Heart inf. < 6 weeks
Inst. angina pectoris
Card. insuff. w/exercise
Hypovolemia
Catecholamine
Asthma
COPD
Respirat. insufficiency
Immunosuppression
Liver failure
Dialysis / ARF
Hyperthyroidism
Diabetes mellitus
Obesity
Pregnancy
Sepsis
Premature birth
Ileus / aspiration risk
Difficult intubation

Urgency
Elective procedure
Urgent
Emergency
PONV
10 20 40 60 80%

ASA
I
II
III
IV

1st OP diagnosis ICD-10

2nd OP diagnosis ICD-10

V
Brain dead
Organ
Explantation

Scheduled OP date

Further diagnoses / case history:

Scheduled anesthesia
Endotracheal
Mask / Larynx
Double LT

Axillarv plexus
Additional
Int. plexus / VIP
TIVA
RSI
Regional peripher
CVC
Artery
Femor. nerve block
Postop. PCA / EDA

Spinal
Peridural
Stand by / Analgos.

Checkliste fr die Station

To do

Repeat anesthesia
Long-term medicationi
No
Antipsychotics
Anticonvulsants
Analgesics

Signature

Premedication date

Time

Premedication / Medication / Dose / Application

To do

Signature

Lab

Blood type

ECG

Consult

Own blood

Pulmonary function

Other blood in the theatre

Chest x-ray

FFP in the theatre

Duration of preoperative visit

Preoperative visit
none
5
5
other
only visit
10
10
records incomplete
2nd visit
20
20
results missing
> 2 visits
30
30
patient not informed
Audiovisual pat. orientation
patient absent
Type of service
Location
Other
NS
OT
Ward
OC
Sa / Su / Holiday
Anesthesia-Outpatient
Anesthesist
Signature

Time

Signature Further instructions

Evening before

Rhesus

Own FFP

OP day

Other blood on demand

No drinking after:
Phone +49 (40) 41 62 66-0 06.07 2007087/1216/1
Parts of this form are patent pending at the German Patent Office.

No eating after:

Last name

First name

Anesthesia

Date of birth

12345678-12
Success of premedicat. Date
Room
Position
Rev. Trend.
good
no meds
Back
Lithotomy
over-dose
Prone
Right side
unsatisfactory
Trendel.
Left side
Anesthetic technology General
Regional
Analgosedation
Stand by
TIVA
Combination
Spinal
Epidural
Ind.
inhalative
i.v./i.m. Aufr.
inhalative
i.v.
balanc.
CSE
Endotrach. Additional
O2
Airway
VIP
Size
Larynxmask
nasal
Tracheo.
Guedel
ISP
Mask
Spiral tube
f/Trach
Wendl
lumbal
Larynxtube
Double LT
Bronch.
T-change
thoracal
IPPV
SIMV
Ventilation mode
w/cath.
Device
PCV
Jet
closed
Highflow
spont.

assist.

:00

Thi

:15

:30

1,0 l/m
:45

:00

< 0,5 l/m

:15

:45

:00

Surgeon

Puncture

axillary
Sciatic nerve block
Nervous femoralis block
Infiltration anesthesia
Regional i.v.
Foot block
Upper extremity
Lower extremity

Effect

lies

:30

Kn./Elb. Procedure
Seated
Shifted
Other

:15

Anesthesist

Number
Needle
Tunnel

Personnel

Depth
Length

left
right

C unplanned
T-change

:30

:45

:00

:15

NS
OC

OT
Sa/Su/H

NS
OC

OT
Sa/Su/H

Stimulation

:30

:45

:00

:15

:30

:45

Eto Pro

Rem Fen Suf Mo

Piri

Suc Atr

Pan Miv

Cis

Des Iso

Sev O2

ANESTHESIA

Bupi Ropi Lido Scan

Kate Adr Akr

Urap

Antib Nitr MCP 5HT

Balance

Atro Antidot
E'lyte NaCl G5
Hes Gel
FFP Sav FEK EEK
Syringe pump

IBC

SPC

Blood loss

MAT

Short anesth. Dbl. doctor visit

Stand by
Anesth. periods
Single

Intake

No OP

Total

Output

OP periods

V
V
V

Time of log start

Measures

V
220

ECD lead

Cuff

RSI

N. inv. BP

AnCon

GFT

O2

Temp

Heat

Relax

CVP

inv. BP

ECG ST

Bronch

PCWP

Massivtr. PAP
Pace

Defibrill.

Cold
ICP

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 o'clock OP standby 5 10 20 40 80 Min.

:15

:30

:45

:00

:15

:30

:45

:00

:15

:30

:45

:00

:15

:30

:45

:00

200

200

200

200

200

180

180

180

180

180

160

160

160

160

160

140

140

140

140

140

120

120

120

120

120

100

100

100

100

100

80

80

80

80

80

60

60

60

60

60

40

40

40

40

40

20

20

20

20

20

CardOut

Reanim. SvO2
EEG PICCO

SaO2

SjO2

FiO2

EtCO2
RESP

AMV

Paw/

PEEP

Sonstiges

Log to follow
:30

:45

Peripher venous
lies
1
2
3
CVC / PAC
lies
V. jug. int.
V. jug. ext.
V. subclavia
V. basilica
V. femoralis
Single lumen
Double lumen
Triple Lumen
PAC
Shaldon
Sheath
X-ray monit.
ECG monit.
Artery
lies
positioned
A. rad.
A. fem.
A. dors. ped.

Remarks / Lab

Cesarean section
Newborn care
Obstetrics
Polytrauma
Organ explant.
Diagnost. proc.
AF-U
Other 1
I
Other 2
II

:15

Access changed
arterial
venous
Grade

III
IV

Time

AF-U

none

Grade

I
II

III
IV

Phone +49 (40) 41 62 66-0 06.07 2007087/1217/1

Parts of this form are patent pending at the German Patent Office.

Time

AF-U

Date / Name / Signature

Last name

First name

Recovery room

Date of birth

12345678-12
Personnel

AF-U
NS
OC

OT
Sa/Su/H

NS
OC

OT
Sa/Su/H

NS
OC

OP
RR

OT
Sa/Su/H

:15

:30

Pflegeman. im AWR
Number of personnel
1 2 3 4

V
:00

OPS-301
1

III
IV
:45

none

AF-U

III
IV

I
II

Time

III
IV

I
II

OP
RR
:00

Piri

I
II

OP
RR

Grade

3
:15

:30

:45

:00

:15

:30

:45

:00

:15

gew. entfernt

Bandage change

Continued ventilation (hrs)

0,5 1 2 4 8 16

Lab

:30

Endotrach. aspiration

:45

PCA Til

Urap Clon Nitra

RR

Mid Prop
Cate Adr Akr

Epi

Antib Insul Nitro

5 HT-Ant. MCP DMH Haldol

Balance

Bupi Ropi Lido Scan

E'lyte NaCl G5
Hes Gel
FFP Sav AEC OEC
Syringe pump

Thorax Drainage

Drainage

Secondary hemorrhage
spon.

BSC

IBC

SPC

GFT

Stool

Vomit

Other

RR periods

V
V
V

Time of log start

Manahmen
ECG lead

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 o'clock
:00

Cuff

:15

:30

:45

:00

:15

:30

:45

:00

:15

:30

:45

:00

GFT

:30

:45

Other
RR evaluation
Arrival
Transfer
Awareness
awake
wakeable
unconscious
Breathing
unimpaired
impaired
intubated
Skin color
rosy
pale, ict.
cyanotic
Cardiovascular
stable
unstable
Miscellaneous
Nausea / vomit
Constant pain
Shivering
Restlessness

Transfer from OP
Ward
ICU
Home
ICS
Another hospital
Transport./accomp.
Died
Other
Postoperative Instructions
Standard care

200

200

200

N. inv. BP

Temp

Heat

200

Inv. BP

PAC

CVP

180

180

180

180

X-ray

Pace

Cold

160

160

160

160

Bed gate

Fixation

ECG ST

140

140

140

140

Defibrill.

Reanim.

120

120

120

120

100

100

100

100

80

80

80

80

60

60

60

60

40

40

40

40

20

20

20

20

Breathing

Log to follow
:15

In-dwelling canula

Category of care
1 2 3 4

Dicl Para Meta CoxII

Nif

Drainage

PCA

PCIA

NFC

Pain (VAS) during transfer

At rest

0 1 2 3 4 5 >5

In motion

0 1 2 3 4 5 >5

SaO2

Recommendations for the ward

spontan

O2 l/min

Drinking allowed after:

CPAP

RESP

Eating allowed after:

BP / Pulse check:

Continued ventilation
Pain score (VAS / NAS)

Plexus

every

At rest

min. until

O2 administration

In motion
Awareness / Neurology
Sedation
Sensitivity
Motor skills

right

Continous reaction

left

Comments

Date / Time / Signature

Care:

Physician:

Phone +49 (40) 41 62 66-0 06.07 2007087/1217/1

Parts of this form are patent pending at the German Patent Office.

am/pm

Blood products log

Patient information
Patient label

Patient no. / Code

Blood type

Bedside-Test
A

AB

Please adhere this in the upper left corner of the duplicate!

Signature

Anesthesia date

Lab

Page count

Last name

Date of birth

Rh pos.

AB
Rh neg.

Exact blood type

1
6

2
7

3
8

4
9

5
10

Street address

City, State, Zip

Complications with
1
7

2
8

3
9

4
10

5
11

6
12

Insurance provider

Please write numbers like this:

Barcode label(s)
OEC
FFP
AEC
AFFP
ATIII

1 Manufacturer / ml

Batch no.

Cellsav.
Thromb.
HA
PPSB
Fibrinog.

7 Manufacturer / ml

Batch no.

time

Batch no.

Cellsav.
Thromb.
HA
PPSB
Fibrinog.

8 Manufacturer / ml

Batch no.

time

Batch no.

Cellsav.
Thromb.
HA
PPSB
Fibrinog.

9 Manufacturer / ml

Batch no.

time

Batch no.

Cellsav. 10
Thromb.
HA
PPSB
Fibrinog.

Manufacturer / ml

Batch no.

time

Batch no.

Cellsav. 11
Thromb.
HA
PPSB
Fibrinog.

Manufacturer / ml

Batch no.

time

Batch no.

Cellsav.
Thromb.
HA
PPSB
Fibrinog.

OEC
FFP
AEC
AFFP
ATIII

Cellsav.
Thromb.
HA
PPSB
Fibrinog.

OEC
FFP
AEC
AFFP
ATIII

Cellsav.
Thromb.
HA
PPSB
Fibrinog.

OEC
FFP
AEC
AFFP
ATIII

Cellsav.
Thromb.
HA
PPSB
Fibrinog.

time

OEC
FFP
AEC
AFFP
ATIII

6 Manufacturer / ml

OEC
FFP
AEC
AFFP
ATIII

time

OEC
FFP
AEC
AFFP
ATIII

5 Manufacturer / ml

Cellsav.
Thromb.
HA
PPSB
Fibrinog.

time

OEC
FFP
AEC
AFFP
ATIII

4 Manufacturer / ml

OEC
FFP
AEC
AFFP
ATIII
time

OEC
FFP
AEC
AFFP
ATIII

3 Manufacturer / ml

Cellsav.
Thromb.
HA
PPSB
Fibrinog.

time

OEC
FFP
AEC
AFFP
ATIII

2 Manufacturer / ml

OEC
FFP
AEC
AFFP
ATIII

time

Notes

Phone +49 (40) 41 62 66-0 06.07 2007087/1217/1

Parts of this form are patent pending at the German Patent Office.

Cellsav. 12
Thromb.
HA
PPSB
Fibrinog.

Manufacturer / ml

Batch no.
time

Patient anesthesia survey

Gender
female

Age (years)

Date

Anesthetized on:

Patient no.

male
Completely true / always true
Mostly true
Somewhat true
Not true / never true

Completely true / always true

Mostly true
Somewhat true
Not true / never true

The elective procedure was explained to

me by the doctors sufficiently and clearly
enough for me to understand.

Nein

Ja

Following the procedure I was very thirsty;

but I was not allowed to drink anything.

Nein

Ja

I was informed of the schedule for the

procedure. Everything proceeded
according to this schedule.

Nein

Ja

Following the procedure I was able to use

the toilet with no assistance.

Nein

Ja

I was notified of the results of my tests in a

manner that was timely and clear enough
for me to understand.

Nein

Ja

I feel well enough again that I am now

able to take care of myself completely.

Nein

Ja

Nein

Ja

In speaking with the doctors, I was able to

have a say in how much I was told and the
manner in which it was explained.

Nein

Ja

Nein

Ja

The catheter and tubes were uncomfortable

(e.g. stomach tube, urinary catheter,
drainage and infusions).

Nein

Ja

I was able to get plenty of rest and

recovered wll.

Nein

Ja

I was able to sleep well at night without

being disturbed.

Nein

Ja

Nein

Ja

The personnel take the patients seriously

and never make the patients feel
vulnerable or helpless.

Nein

Ja

My symptoms were adequately monitored

and treated.

Nein

Ja

The caregivers and doctors made every

effort to be friendly and attentive.

Nein

Ja

There was adequate personnel available

and they all worked well together.

Nein

Ja

I had problems with my digestion.

I felt nauseous or hat to throw up.

I was certain that the doctors were making

decisions to my benefit.

Nein

I was treated by the same doctors I had

met before the procedure.

Nein

Ja

In the lead up to the procedure I was

scared and during waiting periods I was
anxious and upset.

Nein

Ja

I was freezing or shivering before or after

the procedure.

Nein

Ja

Ja

I now feel robust, fit and active again.

I quickly regained control over my body
following the procedure.

Nein

Following the procedure I was too

weak to sit up in bed, swallow
properly or cough.

Nein

Following the procedure I quickly

recovered and was able to express
myself clearly.

Nein

Following the procedure I received

sufficient information about my
progress and results.

Nein

The area around where they

operated was very painful.

Nein

Ja

I received good treatment and

felt safe in the hospital.

Nein

Ja

I had pain in other parts of my body,

such as my head, throat, back,
chest or joints.

Nein

Ja

I was able to find my way around the

hospital easily (e.g. by using the signage
and reading the patient information.)

Nein

Ja

Nein

Ja

The room and the hospital were impeccably

clean and well equipped.

Nein

Ja

Nein

Ja

Nein

Ja

The pain was out of control and

should have been treated better.
I had trouble urinating.

Ja

Ja

Ja

Ja

The care at the hospital was excellent.

Do you have other important issues, complaints or worries you would like to tell us about that are
not included in this survey? If so, please use the reverse side of this form.
Thank you!

Phone +49 (40) 41 62 66-0 06.07 2007087/1218/1

Parts of this form are patent pending at the German Patent Office.

Eberhart, Kranke, Simon, Celik: PPP33-survey form

Awarded the LILLY QUALITY OF LIFE-PRIZE in 2004
Infos www.ppp33.de or E-Mail: info@ppp33.de