ADA Sample Sedation – Anesthesia Record Name: M D.O. B.( dd / mm / yyyy) F Age: Wt : lbs kg / / ASA: 1 2 3 4 Allergies: Record #: NPO for _______ hours Mallampati I II III IV Date:  Equipment Checked / /  Pt Time Out Pre-op Medications: Procedure(s): Surgeon(s): Sed-Anes provider/assistant(s) Sed-Anes start @: Airway screen in @: Airway screen out @ Sed-Anes:end @ Recovery area in @ Time (15 min. intervals) Sedation-Anesthesia Notes O2 liters /min N2O liters/min Sevo Des Iso vol % Drugs and route:: Fluids: LA: NS LR D5LR  GA Deep Sed  Moderate Sed Minimal Sed (mL) ECG Rhythm SpO2 (%) EtCO2 (mm Hg) Resp Rate / min TV (mL)  Vent PEEP/PIP (cmH2O) Spon: SV Assist: AV Cont: CV Temp °C - °F Site: Time-line Symbols: Monitors  ECG  NIBP  Pulse Ox  Capnograph  Precordial Stethoscope  Temperature  Nerve Stimulator Size (g): R  Hand  Arm  Saph  Difficult IV L  Wrist  ACF  Foot Fluid Totals Fluids (mL): EBL (mL): Urine (mL): Airway  Nasal Cannula  Mask Airway Needed? Y N Ventilation:EasyDifficult  Oral  ETT  Nasal R L Size: @ cm  Cuff  Air  LMA Size:  Flex Laryngoscope blade:# Grade: I II III IV  Blind  Fiberoptic  Magill  Difficult Attempts Extubation  Awake  Asleep Discharged @ ˅ = Systolic BP ˄ = Diastolic BP o = Heart rate 220 200 180 160 140 120 100 80 60 40 20 Recovery Area Vital Signs Time _______ VS ______________________________________________ Recovery Notes  Report given to recovery personnel Time _______ VS ______________________________________________ Time _______ VS ______________________________________________ Time _______ VS ______________________________________________ Time _______ VS ______________________________________________ Discharge Summary  Awake, responsive & oriented  Heart rate & BP WNL  Minimal/no PONV  SpO2 > 94% or at pre-op value Time _______ VS ______________________________________________  Instructions discussed: escort patient  Post op pain controlled  Received written post op instructions  All questions answered prior to d/c  Pt discharged from office in care of____________________________________