| Date of Assessment: | Age: yrs | Gender: M F | Height: cm | Weight: kg | BMI: kg/m² |
| Planned Procedure: | Urgency: Elective Urgent Emergency | ||||
| Surgeon/Service: | Scheduled Date: | ||||
| BP: ___/___ mmHg | HR: ___ bpm | RR: ___ /min | SpO2: ___ % (RA) | Temp: ___ °C BSL: ___ mg/dL | |
| Allergen / Drug | Type of Reaction | Severity | Details / Management |
|---|---|---|---|
| Rash/Anaphylaxis/GI/Other | Mild/Moderate/Severe | ||
| Latex Allergy? No Yes → Latex-free setup required | Food Allergies? No Yes: _______________________ |
| Medication Name | Dose | Frequency | Indication | Last Dose Taken | Peri-Op Plan |
|---|---|---|---|---|---|
| Continue Hold | |||||
| Continue Hold | |||||
| Continue Hold | |||||
| Continue Hold | |||||
| Continue Hold | |||||
| Continue Hold |
| Anticoagulation/Antiplatelet Therapy: | ||
| Warfarin (held ___ days) INR: ___ | Aspirin (held ___ days) | Clopidogrel/Plavix (held ___ days) |
| Rivaroxaban/NOAC (held ___ days) | Heparin/LMWH (held ___ hrs) | None |
| Herbal/Supplements: None Yes: ___________________________________ (Held ≥7 days?) | ||
| ☑ | Condition | Details / Severity / Control / Medications |
|---|---|---|
| Hypertension (HTN) | Control: Well Poorly | Meds: __________________________ | BP Today: ___/___ | |
| Coronary Artery Disease (CAD) | Stable: Y N | Last MI: _______ | Angina: Y N | CCS Class: I/II/III/IV | |
| Previous MI / ACS | Date: __________ | Stent: BMS DES None | On DAPT: Y N | |
| Congestive Heart Failure (CHF) | NYHA Class: I/II/III/IV | EF: ____% | Type: HFrEF HFpEF | Last Echo: _______ | |
| Valvular Heart Disease | Type: AS AR MS MR | Severity: Mild/Mod/Severe | Details: __________ | |
| Arrhythmia | Type: AFib AFL VT SVT Other: _________ | On anticoag? _______ | |
| Pacemaker / ICD / AICD | Type: __________ | Date implanted: _________ | Indication: _____________ | Last interrogation: _______ | |
| Peripheral Vascular Disease | Claudication Rest pain Amputation | Stents/Grafts: __________________ | |
| Congenital Heart Disease | Type: _________________________ | Corrected: Y N | Details: ______________ | |
| Pulmonary Hypertension | PA Pressure: _____ mmHg | On therapy: Y N | Drugs: _______________________ |
| Functional Capacity: ≥4 METS (Good) <4 METS (Poor) | Can climb 2 flights? Y N |
| Cardiac Risk: Low Intermediate High | RCRI Score: ____ | Cardiac consult needed? Y N |
| ☑ | Condition | Details / Severity / Control / Medications |
|---|---|---|
| Asthma | Control: Well Poorly | Inhaler: __________ | Last attack: ________ | Ever intubated? Y N | |
| COPD / Emphysema | Severity: Mild/Mod/Severe | FEV1: ____% | Home O2: Y N ___L/min | Exacerbations/yr: ____ | |
| Obstructive Sleep Apnea (OSA) | Diagnosed: Y Suspected | CPAP/BiPAP: Y N Settings: _____ | STOP-BANG: ____/8 | |
| Recent URTI (last 2 weeks) | Resolved Active symptoms | Symptoms: _______________________ | Postpone? Y N | |
| Pneumonia / Bronchitis | Recent: Y N Date: ________ | Hospitalized? Y N | Resolved? Y N | |
| Tuberculosis (TB) | Status: Active Treated Old TB | On treatment: Y N | Precautions needed: _____ | |
| Restrictive Lung Disease | Type: ILD Fibrosis Other: __________ | TLC: ____% | DLCO: ____% | |
| Smoking History | Status: Current Former (quit: _____) Never | Pack-years: _____ | Quit ≥8 weeks? _____ | |
| Dyspnea on Exertion | Onset at: Rest Minimal Moderate Severe exertion | Orthopnea: Y N |
| Baseline O2 requirement: Room Air O2 at ___L/min via __________ | SpO2 today: ____% |
| Pulmonary Risk: Low Moderate High | Post-op respiratory plan: ____________________ |
| ☑ | Condition | Details / Medications / Baseline Status |
|---|---|---|
| Stroke / TIA / CVA | Date: _________ | Residual deficit: Y N Details: ______________ | On anticoag: _______ | |
| Seizure Disorder / Epilepsy | Type: _________ | Frequency: ________ | Last seizure: ________ | Medications: ____________ | Controlled: Y N | |
| Dementia / Cognitive Impairment | Type: Alzheimer's Vascular Other | Baseline: _______ | Consent capacity: Y N | |
| Parkinson's Disease | Duration: _____ yrs | Medications: _________________ | Timing critical: Y N | Dysphagia: Y N | |
| Multiple Sclerosis (MS) | Type: RRMS PPMS | Last relapse: ________ | Medications: ______________ | Autonomic issues: Y N | |
| Spinal Cord Injury | Level: _____ | Complete/Incomplete | Autonomic dysreflexia risk: Y N | Baseline motor/sensory: ______ | |
| Back Problems / Spine Surgery | Level: _________ | Hardware present: Y N | Chronic pain: Y N | Regional contraindication: Y N | |
| Muscular Dystrophy / Myopathy | Type: ________________________ | Cardiac involvement: Y N | Resp muscle weakness: Y N | |
| Rheumatoid Arthritis (RA) | C-spine involvement: Y N | TMJ limitation: Y N | Airway concern: Y N | Medications: ______ | |
| Myasthenia Gravis | Thymectomy: Y N | Medications: ____________ | Recent crisis: Y N | Resp weakness: Y N |
| ☑ | Condition | Details / Control / Medications |
|---|---|---|
| Diabetes Mellitus | Type: 1 2 | Duration: ___yrs | HbA1c: ___% (Date: ___) | Insulin: Y N | Oral agents: _________ | |
| Diabetic Complications | Neuropathy Nephropathy Retinopathy CAD Gastroparesis Autonomic | |
| Thyroid Disease | Hypothyroid Hyperthyroid | TSH: ____ (Date: ___) | Medications: _________ | Goiter: Y N | |
| Adrenal Insufficiency | Primary Secondary | On steroids: Y N Dose: ______ | Stress dose plan: __________ | |
| Chronic Steroid Use | Duration: ______ | Current dose: _______ mg/day | Indication: ______________ | Stress dose needed: Y N | |
| Chronic Kidney Disease (CKD) | Stage: I/II/III/IV/V | Creatinine: ____ | eGFR: ____ | On dialysis: Y N Type: HD/PD | Last: _____ | |
| Renal Transplant | Date: ________ | Baseline Cr: ____ | Immunosuppression: _________________ | Rejection episodes: Y N | |
| Liver Disease / Cirrhosis | Etiology: _________ | Child-Pugh: A/B/C | MELD: ____ | Ascites: Y N | Varices: Y N | |
| Hepatitis (B / C / Other) | Type: _______ | Active: Y N | Viral load: _______ | On treatment: Y N | Precautions: _____ | |
| GERD / Hiatal Hernia | Severity: Mild/Mod/Severe | Medications: __________ | Aspiration risk: Low High | RSI needed: Y N |
| ☑ | Condition | Details / Current Status / Treatment |
|---|---|---|
| Anemia | Type: ___________ | Hb: ____ g/dL | Chronic: Y N | Transfusion history: _____ | Threshold: ____ | |
| Bleeding Disorder | Type: Hemophilia vWD ITP Other: _______ | Factor level: ____ | Hematology consult: Y N | |
| Sickle Cell Disease | Type: SS SC Trait | Last crisis: ________ | Baseline Hb: ____ | Transfusion plan: _________ | |
| Thrombophilia / DVT/PE History | Type: _____________ | Date: _______ | IVC filter: Y N | Anticoag: _______ | Duration: ________ | |
| Malignancy / Cancer | Type: ____________ | Stage: _____ | Active treatment: Y N | Chemo/RT: _______ (Last: ___) | Remission: Y N | |
| Chemotherapy History | Agents: ________________ | Cardiotoxic: Y N | Pulm toxic: Y N | Last cycle: ________ | |
| Radiation Therapy | Site: ___________ | Date: ________ | Airway/Neck radiation: Y N | Fibrosis concerns: Y N | |
| HIV / AIDS | CD4: _____ | Viral load: ________ | On HAART: Y N | Opportunistic infections: __________ | |
| COVID-19 History | Date: ________ | Severity: Mild/Mod/Severe | Hospitalized: Y N | Residual symptoms: ___________ |
| ☑ | Condition | Details / Medications / Management |
|---|---|---|
| Psychiatric Disorder | Type: Depression Anxiety Bipolar Schizophrenia | Meds: _________ | Stable: Y N | |
| Substance Abuse / Dependence | Type: Alcohol Opioids Other: _______ | Active: Y N | Last use: _____ | Tolerance issues | |
| Chronic Pain / Opioid Use | Duration: ______ | Daily opioid: _______ mg OME | Tolerance: Y N | Pain management plan: _________ | |
| Pregnancy (if female) | Currently pregnant: Y N | Weeks: ____ | LMP: _______ | Pregnancy test: Pos Neg N/A | |
| Obesity / Metabolic Syndrome | BMI: _____ kg/m² | Class I II III | OSA: Y N | Positioning issues: Y N |
Previous Anesthesia / Surgery? No Yes (Details below)
|
Anesthesia-Specific Complications: Difficult intubation / airway Prolonged PACU stay / delayed emergence PONV (severe) Awareness under anesthesia Aspiration Prolonged paralysis (succinylcholine) Local anesthetic toxicity Neuraxial complications (PDPH, epidural hematoma) Other: _______________________________ |
| FAMILY HISTORY OF ANESTHESIA COMPLICATIONS: | |
| Malignant Hyperthermia (MH)? No Yes Unknown Details / Relative: ____________________________ |
Pseudocholinesterase Deficiency? No Yes Unknown Details: _______________________________________ |
| Other familial anesthesia problems: _____________________________________________________ | |
|
Tobacco: Never smoker Current: ___ cigarettes/day Former: Quit _____ ago Pack-years: ______ |
Alcohol: None Social (drinks/week): ___ Heavy use History of withdrawal CIWA protocol needed: Y N |
Recreational Drugs: None Marijuana Cocaine Opioids (non-prescribed) Other: ___________ Last use: ____________ |
| Parameter | Findings | |
|---|---|---|
| Mallampati Classification | Class I Class II Class III Class IV | |
| Mouth Opening (Inter-incisor distance) | ≥3 cm (Normal) <3 cm (Limited): _____ cm | |
| Thyromental Distance (TMD) | ≥6 cm (Normal) <6 cm (Short): _____ cm | |
| Neck Mobility / Extension | Full (Normal) Limited Fixed / Collar | |
| Dentition | Good Loose teeth Caps/Crowns Dentures (removed) Edentulous | |
| Facial Hair / Beard | None Present (may affect mask ventilation) | |
| Jaw / TMJ Pathology | Normal Receding mandible TMJ limitation Micrognathia | |
| Neck Anatomy | Normal Short neck Bull neck Thick neck (circumference: ___cm) | |
| Airway Masses / Pathology | None Goiter Tumor Abscess Stridor Other: _________ | |
| Previous Airway Surgery | None Tracheostomy Neck dissection Radiation Other: ________ | |
|
DIFFICULT AIRWAY PREDICTED? NO YES Difficult Mask Ventilation? NO YES Difficult Laryngoscopy? NO YES |
If YES, Plan: Awake fiberoptic intubation Video laryngoscopy LMA / Supraglottic device Difficult airway cart ready ENT backup / Surgical airway Other: ___________________ |
| Test | Result | Date | Normal Range | Action if Abnormal |
|---|---|---|---|---|
| Hemoglobin (Hb) | _____ g/dL | _________ | M: 13-17 / F: 12-15 | Optimize Transfuse OK |
| Hematocrit (Hct) | _____ % | _________ | M: 40-50 / F: 36-44 | |
| Platelets (Plt) | _____ x10³ | _________ | 150-400 | Consult Transfuse OK |
| White Blood Cells (WBC) | _____ x10³ | _________ | 4-11 | Investigate OK |
| INR | _____ | _________ | 0.8-1.2 | Reverse Delay OK |
| PTT / aPTT | _____ sec | _________ | 25-35 | Investigate OK |
| Sodium (Na) | _____ mmol/L | _________ | 135-145 | Correct OK |
| Potassium (K) | _____ mmol/L | _________ | 3.5-5.0 | Correct urgently OK |
| Creatinine (Cr) | _____ mg/dL | _________ | 0.6-1.2 | eGFR: ____ OK |
| Blood Urea Nitrogen (BUN) | _____ mg/dL | _________ | 7-20 | |
| Glucose (Random) | _____ mg/dL | _________ | 70-140 | Diabetic protocol OK |
| HbA1c (if diabetic) | _____ % | _________ | <7% | Optimize if >8% OK |
| Pregnancy Test (β-hCG) | Pos Neg | _________ | N/A if male/post-menopausal | Consult OB if positive |
| Diagnostic Test | Done? | Findings / Interpretation |
|---|---|---|
| ECG (Electrocardiogram) | Yes N/A | Date: _______ | Normal Abnormal: _________________________________ |
| Chest X-Ray (CXR) | Yes N/A | Date: _______ | Normal Abnormal: _________________________________ |
| Echocardiogram (TTE/TEE) | Yes N/A | Date: _______ | EF: ____% | Valves: __________ | Other: _______________________ |
| Pulmonary Function Tests (PFTs) | Yes N/A | Date: _______ | FEV1: ____% | FVC: ____% | Pattern: ____________________________ |
| Stress Test / Cardiac Cath | Yes N/A | Date: _______ | Result: __________________________________________________________ |
| Other (CT/MRI/US) | Yes N/A | Type: _______ Date: _______ | Findings: _________________________________________ |
|
ASA Physical Status: ASA I - Normal healthy patient ASA II - Mild systemic disease ASA III - Severe systemic disease ASA IV - Severe systemic disease that is constant threat to life ASA V - Moribund patient not expected to survive without operation ASA VI - Declared brain-dead patient whose organs are being removed for donor purposes E - Emergency surgery (add E to classification) |
Functional Capacity (METs): ≥4 METS (Good - climb 2 flights) <4 METS (Poor - limited activity) Unable to assess Cardiac Risk (RCRI Score): ___/6 High-risk surgery, IHD, CHF, CVD, DM on insulin, Cr>2 Risk: Low Intermediate High |
|
Pulmonary Risk Assessment: Low risk Moderate risk (COPD/Asthma/OSA) High risk (FEV1 <50%, Hypercapnia) Post-op respiratory support needed: Y N |
Bleeding / Transfusion Risk: Low (<500ml expected) Moderate (500-1500ml expected) High (>1500ml or MTP risk) Blood products: G&S Cross-match ___ units |
| PROPOSED ANESTHESIA TECHNIQUE: | |
|
Primary Plan: General Anesthesia (GA) GETA (Endotracheal) LMA / Supraglottic device RSI (Rapid Sequence) Regional Anesthesia Spinal Epidural Combined Spinal-Epidural (CSE) Peripheral Nerve Block: ____________ MAC / Conscious Sedation Combined Technique (GA + Regional) |
Monitoring & Vascular Access: Standard ASA monitors Arterial line (A-line) Central venous catheter (CVC) Pulmonary artery catheter (PAC) Cardiac output monitoring (FloTrac/PiCCO) TEE (Transesophageal Echo) Neuromonitoring (SSEP/MEP) BIS / Depth of anesthesia monitor Blood gas / Lab access IV Access: ___ peripheral lines (gauge: ___) Special equipment: ____________________ |
| POST-OPERATIVE DISPOSITION: | |
|
PACU (Post-Anesthesia Care Unit) ICU / Critical Care Unit HDU / Step-Down Unit Day Surgery / Ambulatory Ward / Floor Estimated length of stay: _____ days |
Post-Op Pain Management: PCA (Patient-Controlled Analgesia) Epidural analgesia Peripheral nerve catheter Multimodal analgesia (IV/PO) Regional block (single-shot) APS (Acute Pain Service) consult |
| OPTIMIZATION REQUIRED / RECOMMENDATIONS: None, patient optimized Yes (see below) |
|
Medical Optimization: Cardiac clearance / Cardiology consult Pulmonary optimization / Respirology consult Glycemic control / Endocrine consult Hematology consult (bleeding/coagulation) Nephrology consult (renal function) Further investigations needed: _______________________________________________ Medication adjustment: _____________________________________________________ Other: ____________________________________________________________________ |
| Additional Comments / Special Considerations: _____________________________________________________________________________________________ _____________________________________________________________________________________________ |
|
NPO (Nil Per Os / Fasting) INSTRUCTIONS: Standard adult fasting: Solids ≥8 hours, Clear fluids ≥2 hours Modified fasting: Solids ≥____ hrs, Clear fluids ≥____ hrs NPO from: Solids: ________ (date/time) / Clears: ________ (date/time) Medications to CONTINUE on day of surgery: _________________________________________________ Medications to HOLD on day of surgery: _________________________________________________ |
Pre-Medication Orders: Midazolam ___mg PO/IV Acetaminophen ___mg PO Gabapentin ___mg PO Famotidine/PPI ___mg PO Antibiotic prophylaxis: ________ Other: ___________________ Special Instructions: Bring CPAP machine Bring inhalers Other: ___________________ |
I have discussed the anesthesia plan, risks, benefits, and alternatives with the patient/substitute decision-maker. Questions were answered. The patient/SDM understands and consents to the proposed anesthetic technique.
| Date: _____________ Time: _____________ Location: Holding Area OR |
| ☑ | Item | Verified By |
|---|---|---|
| 1.1 Patient identity confirmed using TWO identifiers (Name + MRN or DOB) | ||
| 1.2 Patient identification band present and matches medical record | ||
| 1.3 Patient confirms planned procedure and surgical site (verbal if conscious) | ||
| 1.4 Surgical consent signed, dated, and matches scheduled procedure | ||
| 1.5 Anesthesia consent signed and risks discussed with patient/family | ||
| 1.6 Surgical site marked by surgeon (if laterality/level applicable) N/A | ||
| 1.7 Blood transfusion consent obtained (if anticipated) N/A |
| ☑ | Item | Details / N/A |
|---|---|---|
| 2.1 Allergies reviewed and documented (including drug, latex, food) | ||
| 2.2 Allergy band applied if applicable NKDA | ||
| 2.3 Pre-anesthesia assessment reviewed (ASA, airway, risk factors) | ASA: I II III IV V E | |
| 2.4 Any NEW symptoms or changes since pre-op clinic? (chest pain, SOB, infection, pregnancy test) |
No Yes: ___________ | |
| 2.5 Recent illness / URTI screened (last 2 weeks)? | No Yes: ___________ |
| ☑ | Item | Documentation |
|---|---|---|
| 3.1 NPO instructions followed? |
Last Solid Food: _______ hrs ago Last Clear Liquids: _______ hrs ago |
|
| 3.2 NPO guidelines met? (Solids ≥6h, Clear fluids ≥2h, Breast milk ≥4h) |
Yes No → Discussed with surgeon | |
| 3.3 Aspiration risk assessed? (GERD, hiatal hernia, bowel obstruction, full stomach) |
Low Risk High Risk → RSI planned |
| ☑ | Item | Action / Time |
|---|---|---|
| 4.1 Home medications reviewed (especially cardiac, diabetes, anticoagulants) | Confirmed N/A | |
| 4.2 Cardiac/antihypertensive medications taken today? | Yes No N/A | |
| 4.3 Diabetes medications managed? (insulin held/adjusted) | Yes N/A | BG: _____ mg/dL | |
| 4.4 Anticoagulants/antiplatelets held per protocol? | Yes, held _____ days ago N/A | |
| 4.5 Herbal/supplements discontinued ≥7 days? | Yes N/A | |
| 4.6 Premedication administered (if ordered)? | Drug: _________ Dose: _____ Time: _____ N/A | |
| 4.7 Prophylactic antibiotic ordered and ready? | Drug: _________ Dose: _____ N/A |
| ☑ | Item | Values / Status |
|---|---|---|
| 5.1 Vital signs documented within last hour | BP: ___/___ HR: ___ RR: ___ SpO2: ___% Temp: ___°C | |
| 5.2 Baseline vitals acceptable for surgery? | Yes No → Discussed with team | |
| 5.3 Oxygen requirement documented | Room Air O2 at _____ L/min via _____ | |
| 5.4 Level of consciousness documented | Alert Sedated Other: _____ |
| ☑ | Item | Results / N/A |
|---|---|---|
| 6.1 Required lab results available and reviewed? | Yes N/A | |
| 6.2 CBC (Hb/Plt) reviewed if indicated | Hb: _____ g/dL Plt: _____ N/A | |
| 6.3 Coagulation profile (INR/PTT) if indicated | INR: _____ PTT: _____ N/A | |
| 6.4 Electrolytes/Renal function if indicated | Na: ___ K: ___ Cr: ___ N/A | |
| 6.5 Pregnancy test (females 12-55 yrs) documented | Negative Positive N/A | |
| 6.6 ECG/CXR/Echo reviewed if indicated | Normal Abnormal: _____ N/A | |
| 6.7 Imaging studies available in OR if required | Yes N/A |
| ☑ | Item | Status |
|---|---|---|
| 7.1 Airway examination reviewed (Mallampati, TMD, neck mobility) | MP: I/II/III/IV TMD: >/<6cm Neck: Full/Limited | |
| 7.2 Dentition checked (loose teeth, caps, dentures removed) | Good Risk: ________ | |
| 7.3 Difficult airway identified? | No YES → Equipment ready | |
| 7.4 Difficult airway cart available if needed? | Yes N/A | |
| 7.5 Video laryngoscope/Fiberoptic available if needed? | Yes N/A |
| ☑ | Item | Status |
|---|---|---|
| 8.1 IV access patent and functional | Gauge: _____ Site: _______ None (to start in OR) | |
| 8.2 Additional IV access planned if needed? | Yes, _____ lines N/A | |
| 8.3 Arterial line/CVC planned if indicated? | A-line CVC N/A | |
| 8.4 Blood type & screen completed if indicated? | Blood Type: _______ N/A | |
| 8.5 Blood products cross-matched and available if needed? | Yes, _____ units G&S only N/A | |
| 8.6 Massive transfusion protocol discussed if high-risk case? | Yes N/A |
| ☑ | Item | Plan |
|---|---|---|
| 9.1 Anesthesia technique confirmed with patient | GA Regional MAC Combined | |
| 9.2 Regional anesthesia equipment prepared if applicable | Spinal kit Epidural Nerve block N/A | |
| 9.3 Postoperative pain management plan discussed | PCA Epidural IV/PO Nerve block | |
| 9.4 PONV risk assessed and prophylaxis planned? | Risk: Low Moderate High | Rx: _______ | |
| 9.5 VTE prophylaxis applied (if ordered)? | SCDs TED stockings N/A | |
| 9.6 Temperature management plan (warming devices) | Forced air warmer Fluid warmer N/A | |
| 9.7 Special positioning equipment available? | Yes: __________ N/A | |
| 9.8 Latex allergy precautions if applicable? | Yes, latex-free setup N/A | |
| 9.9 ICU/HDU bed reserved if required? | ICU HDU PACU only | |
| 9.10 Postoperative ventilation planned if needed? | Yes No |
| ☑ | Item | Status |
|---|---|---|
| 10.1 OR room prepared and ready for patient | YES | |
| 10.2 Anesthesia machine checked (ABC check completed) | YES | |
| 10.3 Monitoring equipment functional (ECG, NIBP, SpO2, Capnography) | YES | |
| 10.4 Suction tested and working | YES | |
| 10.5 Emergency drugs available (ephedrine, atropine, succinylcholine, epinephrine) | YES | |
| 10.6 Anesthetic drugs prepared and labeled | YES | |
| 10.7 IV fluids and blood warmer ready | YES | |
| 10.8 Defibrillator in OR and functional | YES | |
| 10.9 Surgeon present in OR area or immediately available | YES | |
| 10.10 Surgical team briefing completed / WHO checklist ready | YES |
I have completed this comprehensive checklist. All items are verified and any concerns have been addressed. The patient is ready to be transferred to the OR and proceed with anesthesia.
To be completed by Anesthesiologist & Circulating Nurse PRIOR to induction (CBAHI / JCI IPSG Compliant)
| STOP CHECK: PATIENT & PROCEDURE | |
|---|---|
| 1. Patient Identity Confirmed? (Two identifiers: Name & MRN/DOB) | YES |
| 2. Surgical Site Marked? (If applicable, does mark match consent?) | YES N/A |
| 3. Consent Form Signed & Verified? (Procedure, Anesthesia, Blood) | YES |
| 4. Patient Allergies Checked? | YES |
| ANESTHESIA SAFETY CHECKS | |
|---|---|
| 5. Anesthesia Safety Machine Check Completed? (ABC check) | YES |
| 6. Medication & Emergency Drugs Available? (Labelled correctly) | YES |
|
7. Pulse Oximetry & Monitors Functional? (SpO2, NIBP, ECG, Capnography ready) |
YES |
| 8. Does the patient have a Difficult Airway / Aspiration Risk? |
NO YES -> Equip Available |
| 9. Risk of Massive Blood Loss (>500ml or 7ml/kg in peds)? |
NO YES -> IV/Fluids Planned |
| 10. Blood Products Verified? (If indicated) | YES N/A |