Obstetric Anesthesia Record Form

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CONTROLS OFF
CYLINDER CONTENTS SUFFICIENT
Milwaukee, Wisconsin
OXYGEN /N2O RATIO ALARM
PIPELINE SUPPLIES
OBSTETRIC ANESTHESIA RECORD
GAS FLOW CONTROLS
VAPORIZERS FILLED
PRE-USE DAILY CHECK LIST
MACHINE LEAK TEST
DATE: ___________________________________
OXYGEN ALARM TEST
Anesthesia Machine Seal #___________________
ABSORBER
PATIENT CIRCUIT ASSEMBLY
Signature_________________________________
PATIENT CIRCUIT LEAK TEST
MONITORS:
PULSE OXIMETER
LLUD
EPI NARCOTICS
PATIENT CIRCUIT FLOW
Delivery Room No. _________________________
PCA
ETCO
LLUD
ECG
PRECORD STETH
VENTILATOR AND ALARM
Date: ____________________________________
TEMP
O ANALYZER
ART BP
CVP
SARA
SCAVENGER
2
ANESTHETIC(S)
HOURS
REMARKS
OXYGEN
CX/STATION
FETAL HEART RATE
ANES LEVEL
QUALITY OF BLOCK
SaO
2
Et CO
2
DELIVERY TIME: _________TO:________
CODE:
200
I-D INTERVAL_______________________
X - X
ANES
180
¤
¤
-
SURG
U-D INTERVAL_______________________
l
PULSE
160
LABOR
B.P.
ANES X______________ X____________
SPONT
140
¤
¤
SURGERY
_________ TO
_________
l
ASSIST
l
120
EBL _________________________
NL
CONTROL
I
INDUCTION
NEONATE WT:
100
U
UTERINE
NEONATE TIME:
INCISION
80
MASK
D
DELIVERY
60
40
IPPS
2
20
ET
NUMBER
FOR REMARKS
LOCATION
IV FLUIDS
RESUS / CARE BY
POSITION
APGAR
1"
5"
GENERAL ANESTHESIA - SEMI CLOSED CIRCUIT W/CO2ABS
REGIONAL BLOCK
EPIDURAL
SPINAL
INDUCTION
PRE-O
RAPID SEQ
CRICOID PRES
HEART RATE
PREP___________________ POSITION___________________
2
AGENTS ____________________________________________
TECHNIQUE _________________________________________
RESPIRATION
MAINTENANCE ______________________________________
INTERSPACE ________ ENTRIES _____ _____ _____ _____
MUSCLE TONE
____________________________________________________
INTERSPACE ________ ENTRIES _____ _____ _____ _____
REFLEX RESPONSE
ET TUBE SIZE ____________ CUFF ___________
ORAL
DEPTH _________________ PARESTHESIAS ______________
COMMENTS
NASAL
COLOR
BLOOD ____________ CSF _________ NEEDLE SIZE _______
CATHETER SIZE_______ DIRECTION______ LENGTH_______
INTUBATION DIFFICULTY - ACTUAL
TOTAL
0______________________________________________100
ANESTHETIC TEST DOSE AGENT _______________________
RECOVERY ROOM
ANALGESIC AGENT ___________________________________
Easy
Impossible
TIME
FLUIDS I.V.
OPERATION/PROCEDURE PERFORMED
CONSCIOUS
LACT. RING ______________ ML OTHER
LABOR ANALGESIA
ABDOMINAL DELIVERY
D5 LACT. RING ___________ ML
____________________
ANES LEVEL
VAGINAL DELIVERY
OTHER
ALBUMIN ________________ ML TOTAL
BP
FORCEPS
_________________ML
PULSE
NAME(S) OF SURGEON(S)
SIGNATURE(S) OF ANESTHESIOLOGIST(S)
RR
WHITE - Medical Records / YELLOW - MCW Anesthesia/ PINK - MCW - QA
OBSTETRIC ANESTHESIA RECORD
AHC X17341 .j (Rev. 09/00)
X17341

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