Complete the anaesthesia record

The anaesthesia record documents the anaesthetic for a case: airway, drugs and fluids, events, vital signs and the recovery score before the patient leaves recovery.

Write the record

1. 1Open Surgery → Anesthesia Records, or select Anesthesia Record on the case.
2. 2Enter the Technique, Induction At and Emergence At.
3. 3Record the airway: Airway Device, Tube Size, Laryngoscopy Grade and Difficult Airway.
4. 4On the first tab add the drugs, fluids and events as they happen. On Vital Signs record the intra-operative values.
5. 5Record Crystalloid Ml, Blood Products Ml and Urine Output Ml.
6. 6On PACU Discharge (Aldrete) score the five items: activity, respiration, circulation, consciousness and oxygen saturation. The Aldrete Total is calculated and shows whether the patient meets the discharge score.
7. 7Note any Complications, then select Sign. Only the anaesthetist of record can sign.

Rules

• Induction and emergence times are required to sign.
• If the Aldrete score is below the threshold or incomplete, an Aldrete Override Reason is required to sign.
• A signed record is immutable and cannot be deleted.

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