Author: Robert

Anesthesia Record

Please X all meds when given

Date

E Sheet Printed? Yes No

Client / Animal	Surgeon	Anesthesia Technicians	Procedures/Plans
Body Wt Kgs/Lbs.	□ Preanesthetic screen __________ Chest auscultation NORMAL ABNORMAL / MM Color ____________ CRT ______sec Pulse __________bpm Pulse deficits? YES NO
Species	Age/Sex	Mental / Status	Physical Status E G F P C
Premed Drugs, Dose, Route, Time		Premed Effect - Ramsay Sedation Score / 1 - 2 - 3 - 4 - 5 - 6 / Did patient vomit? YES NO	Lab Tests – List pertinent abnormalities below
Induction Agent	Amount Drawn Up	Route	Unused Amount
Drug, Dose, Route, Time	Drug, Dose, Route, Time	Drug, Dose, Route, Time	Drug, Dose, Route, Time
Inhalant use - Isoflurane / Sevoflurane / None	Inhalant System / Adult Circle / Ped Circle / Bain W/Block	Reservoir Bag Size	ET Tube Size
IV Catheter Size ________________ / Total # Used ____________	IV Fluid Type	Total Fluids Given	Comments/Alerts

Temp 0F/C
Fluid total

Notes

Time

:			:			:			:			:			:			:			:			:			:			:			:			:

CODES
A-A Anesth
S-S Surgery
T Tournequet
E Extubate
Pulse
V SAP
— MAP
Λ DAP
O2 Sat
CO2
X PPV
D Doppler NIBP
O Oscil. NIBP
I Direct IBP

240
220
200
180
170
160
150
140
130
120
110
100
90
80
70
60
50
40
30
20
10
0
Gas %

Recovery Notes T,P,R MM,CRT Post OP Meds/Dose/Route/Time
Pain/Sedation Scores Completed By _________________________

See Other Side For Pain and Sedation Scales

NATIONAL INSTITUTES OF HEALTH
WARREN GRANT MAGNUSON CLINICAL CENTER
PAIN INTENSITY INSTRUMENTS
Jul-03
Modified FLACC Scale
DATE/TIME
Face
0 - No particular expression
1 - Occasional grimace, withdrawn, disinterested
2 - Frequent grimace, clenched jaw
Legs
0 – Normal position or relaxed
1 – Uneasy, restless, tense
2 – Kicking, or legs drawn up
Activity
0 – Lying quietly, normal position, moves easily
1 – Squirming, shifting back and forth, tense
2 – Arched, rigid or jerking
Cry
0 – No cry, whine(awake or asleep)
1 – Moans or whimpers; occasional yipe
2 - Crying steadily, screams, frequent yipes
Consolability/Stress
0 – Content, relaxed
1 – Reassured by occasional touching, hugging or being talked to, distractible
2 – Difficult to console or comfort
TOTAL SCORE
RAMSAY SEDATION SCALE
1 – Patient anxious, agitated, restless
2 – Patient cooperative, oriented, tranquil
3 - Patient responds to commands only
4 – Brisk response to light gabellar tap or auditory stimulus
5 – Sluggish response to light gabellar tap or auditory stimulus
6 - No response to the stimulus mentioned in items 4 and 5