Anesthesia Handoff Checklist
Use this checklist to communicate essential patient, airway, intraoperative, and postoperative transfer information during anesthesia handoff.
Patient and Procedure Details
Patient Name or Identifier
*
Date of Birth
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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
Anesthesia Type Planned or Used
*
General
Regional
Monitored Anesthesia Care
Local with Sedation
Other
Pre-Anesthesia Status and Intraoperative Course
Allergies
NPO / Fasting Status
*
Last Oral Intake Time
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Airway Concerns / Difficult Airway History
*
Please Select
None
Suspected difficult airway
Known difficult airway
Other
Important Intraoperative Events / Complications
Current Monitoring, Lines/Access, and Devices in Place
ECG
Pulse oximetry
Blood pressure cuff
Arterial line
Central line
Peripheral IV
Foley catheter
Endotracheal tube
Supraglottic airway
Other
Current Infusions / Medications and Last Doses
Estimated Blood Loss, Fluids, and Blood Products Given
Handoff, Postop Plan, and Acknowledgment
Destination / Location for Transfer
*
PACU
ICU
Ward
Other
Immediate Postoperative Concerns or Orders
Receiving Clinician Name
*
First Name
Last Name
Handoff Receipt / Understanding
*
Received and understood
Received with questions
Not yet received
Submit
Should be Empty: