T

PRE-ANAESTHESIA ASSESSMENT
Name
Date Ward
/ / U.R.

Patient
Weight ..............kg Height ............cm BMI ................ Doctor
Patient Identification Label
BP ......... / ......... Pulse .............. Resp ..............

Temp ................
ASA Status (1-6) Gastric Reflux Risk
Fasting Status
Last Food Last Fluid Low Medium High

Proposed Operation Medications (Including Herbal)

Past Medical History

E
Previous Anaesthesia History/Problems
PL Adverse Drug Reactions

Dental Status
M
SYMBOL LEGEND
Smoking Alcohol
Br Bridge
Ch Chipped
Examination Including Airway
Cr Crown
I Implant
p partial
SA

D DENTURE
c complete
G Gingivitis

Investigations L Loose
M Missing
P Pyorrhoea
S Splint
V Veneer
ANAESTHESIA

Dental damage discussed? Yes No

Anaesthesia Planned
Local Sedation

Discussion Regional Sedation

Yes No Regional GA
Written Information Received GA
Written Information Understood
Signature
Risks, Benefits, Alternatives Discussed
Further Questions Addressed? Date / /
To re-order your Anaesthesia Record, please contact the ASA
t 02 9327 4022 | f 02 9327 7666 | www.asa.org.au
Copyright. The Australian Society of Anaesthetists Limited owns the copyright in this material. This material may only be reproduced for commercial purposes with the
written permission of the Australian Society of Anaesthetists Limited.

090811 ASA Anaesthetic Record.indd 1 19/10/2011 3:22:35 PM

 ANAESTHESIA RECORD
Name

Operation Performed Side (Circle)

Right Left U.R.
Date
/ / Doctor
Anaesthetist(s) Patient Identification Label

Surgeon(s)

Monitoring Time
200

SaO2 ETCO2 ECG ART

180
/AA
160
CVP T PAC BIS

E
140
Other: ................................
Vascular Access 120
IV
IV 100
ART
CVC
Other : ......................................
Ventilation
SP
IPPV
IMV
Airway Device & Size
LMA
ETT
80

60

40

20

10
PL
Other: ....................................... 5
Patient Care
M
Eyes 0
Teeth ETCO2
Pressure Areas
SaO2 (%)
Fluid Warmer
FiO2
Warming Blanket
Position BIS
Calf Compression ET AGENT (%)

Drugs & Fluids:

SA

ANAESTHESIA

Regional/Local Anaesthesia Comments Post Op Plan

Site Pain im/sc/oral
PCA
Agent
IT/epid
Volume LA/infusion
Needle Fluids
Nerve Stimulus Ward
HDU/ICU
Comments
Other Ix
Total Urine Output ml
Total Blood Loss ml

Signature Date / /

090811 ASA Anaesthetic Record.indd 2 19/10/2011 3:22:35 PM