Surgical Anesthesia Monitoring Form
Document and monitor anesthesia care and patient status during surgical procedures.
Patient Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Medical Record Number
*
Procedure Name
*
Date and Time of Surgery
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Type of Anesthesia
*
General
Regional
Local
Sedation
Other
Anesthesia Provider
*
Vital Signs Monitoring Table
*
Rows
Blood Pressure (mmHg)
Heart Rate (bpm)
SpO2 (%)
Temperature (°C)
Pre-Induction
Induction
Incision
Every 15 min
Emergence
Post-Op
Anesthesia Drugs Administered (Name, Dose, Route, Time)
Fluids and Blood Products Administered (Type, Volume, Time)
Events or Complications (if any)
Signature of Anesthesia Provider
*
Submit Monitoring Record
Submit Monitoring Record
Should be Empty: