Anesthesia Case Record Form
Record the details of the anesthesia case, including pre-anesthesia assessment, anesthetic plan, intraoperative events, and recovery status.
Patient and Case Information
Patient Name
*
First Name
Middle Name
Last Name
Date of Birth
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Age
Sex
Please Select
Female
Male
Intersex
Other
Medical Record Number
Case / Encounter Number
*
Scheduled Procedure Name
*
Procedure Date and Time
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Operating Room / Location
Surgeon / Proceduralist Name
*
First Name
Middle Name
Last Name
Pre-Anesthesia Assessment
Pre-op Diagnosis / Indication
*
Relevant Medical History
Hypertension
Diabetes
Asthma/COPD
Coronary artery disease
Stroke/TIA
Seizure disorder
Sleep apnea
GERD
Kidney disease
Liver disease
Bleeding disorder
Other
Allergies and Reactions
Fasting / NPO Status
*
Adequate
Uncertain
Not adequate
Not applicable
ASA Physical Status Classification
*
ASA I
ASA II
ASA III
ASA IV
ASA V
ASA VI
Baseline Vital Signs
Airway Assessment
*
Easy
Potentially Difficult
Difficult
Unable to Assess
Pre-Anesthesia Risk Notes
Anesthesia Plan and Intraoperative Record
Planned Anesthesia Type
*
Please Select
General
Regional
Spinal
Epidural
MAC/Sedation
Local
Combined
Other
Actual Anesthesia Type Administered
*
Please Select
General
Regional
Spinal
Epidural
MAC/Sedation
Local
Combined
Other
Induction Agents
Maintenance Agents
Airway Management Details
IV Access Details
Monitoring Used
Pulse Oximetry
Noninvasive Blood Pressure
ECG
Capnography
Temperature
Invasive Arterial Line
Central Venous Access
Neuromuscular Monitoring
Other
Anesthesia Start Time
*
Hour Minutes
AM
PM
AM/PM Option
Anesthesia End Time
*
Hour Minutes
AM
PM
AM/PM Option
Estimated Blood Loss
Fluids Given and Transfusions
Intraoperative Events and Complications
Recovery and Post-Anesthesia Status
Pain Score
*
No pain
0
1
2
3
4
5
6
7
8
9
Worst pain
10
0 is No pain, 10 is Worst pain
Nausea/Vomiting
*
None
Nausea
Vomiting
Both
Post-Op Vital Signs
*
Rows
Value
Heart Rate
1
Blood Pressure
2
Respiratory Rate
3
SpO2
4
Temperature
5
Discharge Readiness
*
Not ready
1
2
3
4
5
6
7
8
9
Fully ready
10
1 is Not ready, 10 is Fully ready
Postoperative Instructions
Adverse Events in Recovery
Destination After Recovery
*
Please Select
Home
Ward
ICU
Step-down Unit
Transfer to Another Facility
Other
PACU Recovery Status Notes
Provider Documentation
Provider Name
*
First Name
Middle Name
Last Name
Role / Title
*
Documentation Signature
Documentation Date and Time
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Submit Case Record
Submit Case Record
Should be Empty: