Maine Medical CenterANESTHESIA RECORDDate:Immediate Pre-anesthesia Exam□ Patient Identifiedi .1 Patient interviewed / examined

Last PO solids. liquids.D Pre-Anesthesia Record reviewed and amended as appropriate□ Anesthesia consent obtained and reviewed□ Premeds given (drug/dose/time) [ ] NONE □ See Nurses' Notes

Risk Factors I 1 NONE i I Other (specify):

PATIENT NAME LABEL #1 OF 4

□ Asthma□ COPDU Smoker□ Respiratory Infection

: Sleep Apnea □ Prior Ml! Hyperlipidemia D Valve Disease

H T N □ A t r i a l a r r h y t h m i a□ C A D □ Ve n t r i c u l a r a r r h y t h m i a

Notes:

□ Congenital HD□ CHFnpvDh c v d

w i□ Seizures □ Liver Disease □ Hx of PONV and/or Motion Sickness□ D i a b e t e s □ S u b s t a n c e U s e □ T r a u m a□ Renal Disease □ Chronic Opiate Use □ Obesity 30 < 39 BMI□ Thyro id D isease D GER □ Morb id Obes i ty > 39 BMI

I evaluated the patient immediately before inductionand find that it is appropriate to proceed with theplanned anesthetic.

Pre-Op ASAAnesthesia Plan:

1 2□ Gen

3 4 5□ SAB

6 E□ Epid

1□ MAC □ Other

Signature/ID/Time (24°) Time:Pre-anes Safety Monitors and Equipment Temperature Pos i t ion Site □ SSC Type of Anesthesia

l , Machine # 22 BP Cuff: UEEG / EP Available Supine 1 GOR# GeneralRA LA RL _L □ Nerve Stimulator r 1 Nasal □ Lithotomy ( 1 SpinalMonitor Check

[ 1 Airway Equip/Drugs □ EKG □ NGT/OGT □ Rectal □ Lateral □ Cath Lab Epidural1 Gas Supply □ O2 Sat 1 ) Fluid Warmer □ PA Cath [ ] Prone i 1 Radiology □ MAC

(" Suction □ ETCO2 □ Blanket Warmer n Bladder' Sitting L~l Endoscopy 2 Block

□ Steth E / P i I HME/Humid 1 ] Oral/Esoph 1 ] Other (specify): □ Procedure RoomAgent Analysis □ Other (specify): [ ] Other (specify): □ OB

□ O2 Analyzer □ All otherA i r w a y Intubat ion Techn iques Other Airway Comments□ ETT asleep / awake □ Pre-oxy I Mask ventilation with ease□ Double lumen oral / nasal __ Rapid Seq. '. Good view of glottis on□ Endobronchial direct / blind □ Cricoid laryngoscopy

blocker 22 Stylette □ Atraumatic intubation/insertion□ Natural Size ID □ Bougie n ETCO2 present□ LMA size: Secured at cm 22 Fiberoptic ' BS present bilaterally

[ J Mask Cuff 1 Teeth intactEyes taped

Blade(s) Difficult airway □ N □ YScope # # attempts

J

Primary Regional Anesthetic Techniques□ Spinal i 1 Steri le prep/drape , iTD without HR A or SAB□ B l o c k N e e d l e : C a t h i n s e r t e d c m□ E p i d u r a l B l o o d Y NS i t e : P a r e s t h e s i a □ Y D N

C S F D Y C N

Drugs: JMarker at skin

Signature/ID/Time (24°)Post-op Pain Management- Regional Techniques□ IV D in situ

□ Epidural □ Block □ Procedure Note completeMA

□ A-Line Note □ in situ Sterile gloves / prep

Signature/ID/Time (24°)□ CVC / □ PAC Note D in situ□ Sterile prep/drapeI ] Hand hygiene/maximal barrier precautions/

chlorhexidine prep/optimal site selection□ Chest x-ray ordered

■ -

Signature/ID/Time (24°)

Signature/ID/Time (24°)Present for the following line(s) and/or block placement(s): DA-Line DCVC D p a c Spinr 1 □Block DEpidural Iffll'll'I*-

Peri-operative Procedures / Events (date and time all entries)Pre-incision antibiotics: □ None ordered □ Started by nursing

IV Antibiotic(s) / Dose(s) / Start infusion time: :

Present for induction: ■H f f l l i l * -Immediately availableand present for all keyportions and monitoredanesthesia care atintervals:

Procedure or incision start time: : IHfflldKR e - d o s e d t i m e : :

Present for emergence: I I T M I i l * -

Breaks: s tar t / end

/ I f f f fl i M * -

/ I B f f l J l t f » >

/ mma*~

1202109047 j See Continuation Sheet

_

5S

u

005561 147052 MMCAR 2 .12 Page 1 o f 2 MEDICAL RECORD I

_

_

_

Maine Medical CenterANESTHESIA RECORDDate:Surgeon: □ as l istedSurgical Procedure(s): Indicate any and all modifiers in addition to description.

G e n e r a l S u r g e r y O r t h p / S p i n eOpen Laparoscopic Above umbil icus Open Arthroscopic Proximal Distal

Below umbilicus Extraperitoneal intraperitoneal Instrumentation Diagnostic

Descript ion: Anesthesiologist Sig / ID Start Time (24°) 1 CRNA/Resident Sig/ID Time(24°) 1-»▶

Case reviewed and care assumed: : / :-*~

3ost-op Diagnosis:Case reviewed and care assumed: : / :Case reviewed and care assumed:

: / :24° Time —1 SeeContinuation

Post-anesthesia 1Events

a>c"53COCD

- QCD1—CDen

S>CD

PooCD

W

i l

NIBP X

Arterial ^

Pulse •

Mean X

Incision-^-

Spont O

Assist 0

Control e

180 EvaluationVital Signs

& TotalsBP160

140 P

RR120 T°

100 PAP

CVP

S A T %

Airway□ Natural1 1 Supported□ intubated

Oxygen[ J Room Air

Nasal cannula 1□ Face Mask□ VentLOC□A l e r t□Arousablef Unresponsive

Totals

80

60

40

S p 0 2 E T C 0 2y " y / /

y y y y y y - ,,.- ■T V R R

y y y / / y y ' y

F I 0 2 P I P y X y > y x ■ ' y J _yE K G

TempBlood GlucoseTO F

O2 liters per min.

IV Fluids m L

EBL m L

Urine Output m L

TRANSFER OF CARE / POST-ANESTHESIA NOTE:□ PACU orders entered□ Muscle relaxant recovery verified

J r A n e s t h e s i a ^Time:

Verbal report given and care transferred

005561 147052 MMC AR 2.12 Page 2 of 2

Signature / ID / Date \ ^ /MEDiCAL RECORD

Anesthesio logy Data Form MMC / SSC

This form will be SCANNED. For 100% accuracy, please do the following:

If you make amistake... fill theentire box then

mark correct one.

ONLY use black pen or #2 pencil.

ONLY mark with a clear [X] or [7] within the box.

ONLYput any written comments in the Comments box.

PATIENT NAME LABEL

KOUL

H

m_ i■IIoX :

LL

if:-:':!.

( -Ozc

A d v a n c e d M o n i t o r s

N O N E D

DbisDeegDepD O t h e r

F i n a l A i r w a yM a n a g e m e n t

De t tI I Awake

I I FiberopticEndoscopeRequired

I I FiberopticLaryngoscopeRequired

□ Na tu ra l

□ L M A

□ M a s k

I n t r a O p A n a l g e s i c / S e d a t i v e

N O N E □

□ F e n t a n y l □ L o c a lInfiltration

□ M o r p h i n e g N S A | [ ) S

Q D i l a u d i d , — | .| | Acetaminophen

I I Remifentanil □ Othe□ Al fentani l

I n t r a O p O b s e r v a t i o n sOther Major Morbidity/Mortality

P r e - O R M e d i c a t i o n

N O N E □I I Midazolam

I I Propofol

I I Acetaminophen

□ NSAIDS

□ An tac id

I I Metoclopramide

□ O t h e r

P r e / l n t r a O p A n t i e m e t i c

NONE □□ S t e r o i d s □ S c o p o l a m i n epatch

□ 5 H T 3 □ E m e n dAntagonist

I I Promethazine□ Ha ldo l

I I MetoclopramideI I Propofol

i n f u s i o n [ J o t h e r +

I n d u c t i o n

NONE □I I Propofol

I I Etomidate

I I Sevoflurane

0 Methohexital

1 I Thiopental

I I Ketamine

I I Midazolam

□ O t h e r

I n t r a O p A n e s t h e t i c /S e d a t i v e

NONE □I I I s o fl u r a n e +

I I Desflurane

I I Sevoflurane

□ N o x

I I Propofol

I I Versed

□ O t h e r

P e r i o p e r a t i v eW a r m i n g

N O N E □

I n t r a O pQ u a l i t y I n d i c a t o r s

Temperature(Measured during the

Convection warming final 30 minutes ofblanket (check both anesthesia time)if applicable)

□ P r e O p

□ In t raOp

I I In-Line Fluid

□ O t h e r

No t Reco rded □□ <36°C

□ >36°C

IntraOp Beta Blocker:

□ Y e s □ N o

M u s c l e R e l a x a n t

N O N E □□ S u x

I I Vecuronium

0 Pancuron ium

1 I Rocuronium

□ O t h e r

M u s c l e R e l a x a n tA n t a g o n i z e dN O N E □

□ Y e s

A c t u a l D i s p o s i t i o n

□ Phase I (PACU)

□ Phase II (ASU)

□ SCU Planned

□ SCU Unplanned

I I Patient Room

□ O t h e r

or <80% for >1 min□ Blue button/STAT page rj Narcan/F|umanzeni| given

□ NO L ISTED OBSERVATIONS

I I Myocardial isch

l~~l Cardiac arrest□ Desaturation <90% for >3 min. □ Myocardial ischemia*

□ Death

Airway/Resp

I I Unable to intubate

| | ExpectedDifficult Intubation

"~| UnexpectedDifficult Intubation

I I Difficult mask airway

I I Reintubation in OR+

I I Pulmonary edema*

I I Bronchospasm*

I I Laryngospasm*

I I Pneumothorax

I I Suspected aspiration

Cardiovascular

I I Arrhythmia*

□ Unable to extubate in OR D My°cardial infarction*

Comments Enter comments for Ql Committee review only.

I I Hypotension (requiringvasopressor infusion)

NeurologicI I Seizure

I I Central nervoussystem injury /Ischemia

Head/Neck TraumaI I Tooth damage

Regional/ProceduralI I Failed regional

(requiring GAorrepeat for any reason)

patient, procedure, implantI I Equipment malfunction*

Specify in Comments ♦ Requiring intervention

I — i „ . . . . . P a t i e n t S a f e t y| | High spinal (requiringairway management) J Incorrect surgical site, side,

I I Local anesthetic toxicity

I I Unintended dural puncture .| | Near miss/Safety concern

~ J V a s c u l a r a c c e s s , — ,c o m p l i c a t i o n L J P a t i e n t B u r n / F i r e

P h a r m a c y / B l o o d B a n k □ P a t i e n t F a l l□ M e d i c a t i o n e v e n t * D i s c h a r g e / P l a n n i n g

□ , ,„„ „»„j _,_,_ „„„.■* ["I Case canceled in ORUnexpected drug reaction '—'

I I Malignant hyperthermia

I I Received bloodtransfusion

I I Unplanned ICU admitMiscellaneous

I I Other (specify inComment Box)

2 4 - 4 8 H o u rO b s e r v a t i o n s □ NO LISTED OBSERVATIONS

I I Intubation

I I Mechanicalventilation

I I Peripheralnerve deficit

I I Central nervoussystem injury

□ Unintended IntraOp □ Tooth damageawareness

□ U n p l a n n e d I C U / ^ P ° ^ lhospital/ER admit

I I Myocardialinfarction*

I I Myocardialischemia*

I I Cardiac arrest

□ Dea th

puncture headache

I I Regional relatedinfection

I I Surgical siteinfection

I I Epiduralhematoma

I I Visual deficit/loss

□ O t h e r(specify inComments Box)

C O N F I D E N T I A L : N o t a M e d i c a l R e c o r d . P l e a s e r e t u r n t h i s f o r m t o t h e A n e s t h e s i o l o g y D e p t . * r \ r \ r \ a ~ 7This record is maintained as part of either (1) a hospital quality program for the identification and prevention of medical injury (including education) 1 /IJz J ZJ L J Ipursuant to the Maine Health Security Act (24 MRSA, chapter 21) or (2) a confidential quality improvement program involving review of medical care ' ^~ ^ ^~ -*- %on behalf of physicians, conducted under the auspices of the Maine Medical Association as authorized under the provisions of 32 MRSA, section 3296.

P o s t - A n e s t h e s i a D a t a

Core Temp: (First 15 min.

2 5

First Blood Sugar

D < 8 0D <36°C D >36°C

D 80-180

+ □ > 1 8 0

H i g h e s t P a i n S c o r e r e p o r t e d : \ Z \ 0 Q l Q 2 D 3 D 4 Q 5 Q 6 Q 7 Q 8 D 9 D 1 0 □ N o t a b l e t o a s s e s s

Post-op Antiemetic:

NONE D

D Yes

Vomiting:

□ No

□ Yes

P a i n S c o r e a t D i s c h a r g e : □ 0 Q l Q 2 Q 3 Q 4 Q 5 D 6 D ? Q 8 Q 9 □ 1 0 □ N o t a b l e t o a s s e s sBramhall Only

Phase I Ready Time:(24 hr. time)

■^ OCD ~

r IC7)0>OS

— £

Q.'SO 0at'a.

I- .S*^ tzQ.O0} a)Q §

"(5°cu SI I(J) 01

IfO Dl

i f

Phase I Discharge Time:(24 hr. time)

P o s t - A n e s t h e s i a O b s e r v a t i o n s □ N O L I S T E D O B S E R V A T I O N S

Other Major Morbidity/Mortality□ Blue Button/STAT page

□ DeathAirway/Resp□ Desaturation <90% for >3 min.

or <80% for >1 min.□ Airway obstruction

requiring support >3 min.0 Reintubation

1 I Mechanical ventilation

I | Flumazenil given

I | Narcan given

[J Muscle relaxantantagonist given

j | Suspected aspiration

I I Pulmonary edema*

□ Bronchospasm*

□ Laryngospasm*

□ Pneumothorax

CardiovascularI I Cardiac arrest

I I Myocardial infarction*

I I Myocardial ischemia*

I I Arrhythmia*

I I Hypertension*

I I Hypotension*NeurologicI I Agitation requiring restraint/drug RX

□ Central nervous system injury/IschemiaI | Delayed emergence >1 hr

I I Peripheral nerve injury

I I Visual deficit/lossHead/Neck TraumaI I Tooth damage

I I Other oropharyngeal injury/pain*

I I Eye injury*

Pharmacy/Blood BankI I Medication event*

I I Unexpected drug reaction*

0 Malignant hyperthermia*

1 I Received blood transfusionPatient Safety

I I Excessive pain*

□ Prolonged NA/*

I I Voiding issues*

□ Bleeding*

Q Unintended IntraOp awareness

Discharge/Planning□ Return to OR

I I Complicated patienthistory not communicated

I | Unplanned hospital admitor 23° stay

□ Unplanned ICU admission

□ Prolonged PACU stayMiscellaneous

□ ENT/Cardiology/ICU consult

□ Other(specify in Comments on front)

» Requiring intervention *Specify in Comments on front

Delay in Discharge Select primary reason below □ NO DELAYS

G ASU unable to accept patient □ Floor unable to take report □ Awaiting transport/escort

•!2 I Q Floor bed not ready □ Awaiting anesthesia signout □ Awaiting surgeon

□ Due to observation noted above.

Q Other (specify in Comments on front)

p i

cu £c/);o

5 8O, ro

CQ _cO °

§ 5

> COU j x

Si0 0

Post Discharge Events

1. Able to contact patient/spouse/parent/significant other who was willing to answer the questions? □ Contacted □ Unable to contact

2 . H a v e y o u b e e n f r e e o f v o m i t i n g s i n c e d i s c h a r g e ? 2 . [ ] Y Q N

3 . W a s y o u r a n e s t h e s i a e x p e r i e n c e s a t i s f a c t o r y ? 3 . Q y Q n

4 . W e r e y o u s a t i s fi e d w i t h y o u r p a i n m a n a g e m e n t ? 4 . Q ] Y Q n

5. During this hospital stay, did your anesthesiologist explain things in a way you could understand? 5. [^Y Qn

6 . H a v e y o u b e e n f r e e o f p r o b l e m s w i t h y o u r w o u n d o r d r e s s i n g ? 6 . Q y Q n

7 . W e r e y o u r h o m e c a r e i n s t r u c t i o n s r e v i e w e d t o y o u r o r y o u r f a m i l y ' s s a t i s f a c t i o n ? 7 . | ~ | Y □ N

8 . P a t i e n t i n s t r u c t e d t o c a l l D r . a s n e e d e d w i t h p r o b l e m s ? 8 . \ Z \ Y D N

£::O

LUX

UJ

-.,IIoz: >a.H;

-'-Q

sO

:'x:y "

Q_lO

; -OZo