Anesthesia Report

Form for reporting anesthesia monitoring

Date(Required)
MM slash DD slash YYYY
Owner Name(Required)
Last Name First Name
Patient Name(Required)
Patient Name
Procedure(Required)
List Pre-Anesthetics(Required)
HOUR:MIN DRUG NAME VOLUME/CONCENTRATION
List Anesthetics(Required)
HOUR:MIN DRUG NAME VOLUME/CONCENTRATION
Gas Anesthetic (write "none" if not used)(Required)
Monitor Points EVERY 5 MIN
HOUR:MIN GAS % HEART RATE RESP RATE MM COLOR CRT SPO2 % BLOOD PRESSURE BODY TEMP
Comments
This field is for validation purposes and should be left unchanged.

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HOUR:MIN	GAS %	HEART RATE	RESP RATE	MM COLOR	CRT	SPO2 %	BLOOD PRESSURE	BODY TEMP

HOUR:MIN	DRUG NAME	VOLUME/CONCENTRATION

HOUR:MIN	DRUG NAME	VOLUME/CONCENTRATION