ADA

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____________________________________