Table 1.
Preoperative |
Intervention (history of present illness, elective vs. emergency, etc.) |
Patient (name, age, sex, ASA status, etc.) |
Past history (medical, surgical, anaesthetic, family, etc.) |
Allergies |
Medications (anticoagulants, antibiotics, cardiac, diabetic, etc.) |
Team (anaesthesia, surgeon, nurses, etc.) |
Intraoperative |
Anaesthetic technique |
Induction |
Airway – Cormack/Lehane |
Equipment (vascular access, monitoring, etc.) |
In & Out (iv fluids, blood products, urine output, blood loss, etc.) |
Injections (neuromuscular blockers, PONV prophylaxis, narcotics, antibiotics, vasopressors, etc.) |
Remaining time |
Haemodynamic and respiratory stability |
Postoperative |
PACU (plan for emergence: extubation/intubation; lab, radiograph, regional, pain, etc.) |
Postoperative orders |
Disposition (ambulatory, floor, monitored bed, ICU, etc.) |
Miscellaneous |
Special clinical/study protocol |
OR planning (following case, set-up and materials, etc.) |
Documentation of transfer of care |
ASA, American Society of Anesthesiologists’ physical status; OR, operating room; PACU, postanaesthesia care unit; PONV, postoperative nausea and vomiting.