ANESTHESIA RELATED

JAIN ENT HOSPITAL

DOC NUM

MODIFICATION OF ANESTHESIA PLAN

S.n
o

dat
e

uhid

S,N
o

dat
e

uhid

S.n
o

dat
e

uhid

Name of pt

event

reason

UNPLANNED VENTILATOR FOLLOWING ANESTHESIA

Name of pt
event
reason

ADVERSE ANESTHESIA EVENT

Name of patient event
reason

PREPARED BY QM APPROVED BY
DIRECTOR

Action
taken

Remarks and sign

Action
taken

Remarks and sign

Action
taken

Remarks and sign

ANESTHESIA RELATED

JAIN ENT HOSPITAL

DOC NUM

ADVERSE DRUG REACTION

S
R
NO
.

DAT
E

S NO.

NAME
OF
PATIEN
T

DATE

PATIEN
T ID

DIAGNOSIS

SIGNATU
RE OF
NURSING
STAFF

BLOOD
COMPONEN
TS

SIGANTU
RE

ADVERSE DURG
REACTION REPORT

PERCENTAGE OF TRANSFUSION REACTION

TYEP OF
TRANSFUSI
WHETHER
ON
TRANSFUSIO
NAME OF
PATIENT
ADMINISTER N REACTION
PATIENT
ID
ED
OCCURRED
WHOLE
WHOL
BLOOD&YES&
BLOOLD
NO

PREPARED BY QM APPROVED BY
DIRECTOR

ACTIO
N
TEKAN

YES&NO

ANESTHESIA RELATED

JAIN ENT HOSPITAL

PREPARED BY QM APPROVED BY
DIRECTOR

DOC NUM

ANESTHESIA RELATED

S NO.

VIAL NAME

JAIN ENT HOSPITAL

MULTIDOSE
DATE OF
OPENING OF
VIAL

VIAL
CAN
BE
USED
TILL
DATE

USAGE
ACTUALLY
USED TILL DATE

DOC NUM

NAME &
SIGN

ANESTHESIA
RELATED MORTALITY
S NO.

DATE

PT ID

PREPARED BY QM APPROVED BY
DIRECTOR

PT
NAME

CASE

ANAESTHESI
A GIVEN

DONY
BY

NAME &
SIGN

ANESTHESIA RELATED
SR NO.

DATE

JAIN ENT HOSPITAL

DOC NUM

RETUREN TO EMERGENCY WITHIN 72 HRS

NAME OF
IP NO. RETURN FRON
REASON
PATIENT
WARD/DISCHAR
GA

PREPARED BY QM APPROVED BY
DIRECTOR

ACTION
TAKEN

SIGNATU
RE

ANESTHESIA RELATED

JAIN ENT HOSPITAL

PREPARED BY QM APPROVED BY
DIRECTOR

DOC NUM

ANESTHESIA RELATED

JAIN ENT HOSPITAL

DOC NUM

MODIFICATION OF ANESTHESIA PLAN

S.no

date

uhid

Name of pt

SR
NO.
S,No

date

NAME OF
PATIENT

DATE

UNPLANNED VENTILATOR FOLLOWING ANESTHESIA

uhid
Name of pt

PERCENTAGE OF TRA

ADVERSE ANESTHESIA EVENT

S.no

date

uhid

Name of
patient

S NO.

PREPARED BY QM APPROVED BY
DIRECTOR

DATE

ANESTHESIA RELATED

JAIN ENT HOSPITAL

PREPARED BY QM APPROVED BY
DIRECTOR

DOC NUM

ANESTHESIA RELATED

JAIN ENT HOSPITAL

DOC NUM

MODIFICATION OF ANESTHESIA PLAN

S.no

date

uhid

Name of pt

SR
NO.
S,No

date

NAME OF
PATIENT

DATE

UNPLANNED VENTILATOR FOLLOWING ANESTHESIA

uhid
Name of pt

PERCENTAGE OF TRA

ADVERSE ANESTHESIA EVENT

S.no

date

uhid

Name of
patient

S NO.

PREPARED BY QM APPROVED BY
DIRECTOR

DATE

ANESTHESIA RELATED

JAIN ENT HOSPITAL

PREPARED BY QM APPROVED BY
DIRECTOR

DOC NUM

ANESTHESIA RELATED

JAIN ENT HOSPITAL

PREPARED BY QM APPROVED BY
DIRECTOR

DOC NUM

ANESTHESIA RELATED

JAIN ENT HOSPITAL

DOC NUM

MODIFICATION OF ANESTHESIA PLAN

S.no

date

uhid

Name of pt

SR
NO.
S,No

date

NAME OF
PATIENT

DATE

UNPLANNED VENTILATOR FOLLOWING ANESTHESIA

uhid
Name of pt

PERCENTAGE OF TRA

ADVERSE ANESTHESIA EVENT

S.no

date

uhid

Name of
patient

S NO.

PREPARED BY QM APPROVED BY
DIRECTOR

DATE

ANESTHESIA RELATED

JAIN ENT HOSPITAL

PREPARED BY QM APPROVED BY
DIRECTOR

DOC NUM

ANESTHESIA RELATED

JAIN ENT HOSPITAL

DOC NUM

MODIFICATION OF ANESTHESIA PLAN

S.no

date

uhid

Name of pt

SR
NO.
S,No

date

NAME OF
PATIENT

DATE

UNPLANNED VENTILATOR FOLLOWING ANESTHESIA

uhid
Name of pt

PERCENTAGE OF TRA

ADVERSE ANESTHESIA EVENT

S.no

date

uhid

Name of
patient

S NO.

PREPARED BY QM APPROVED BY
DIRECTOR

DATE

ANESTHESIA RELATED

JAIN ENT HOSPITAL

PREPARED BY QM APPROVED BY
DIRECTOR

DOC NUM

ANESTHESIA RELATED

JAIN ENT HOSPITAL

PREPARED BY QM APPROVED BY
DIRECTOR

DOC NUM

ANESTHESIA RELATED

JAIN ENT HOSPITAL

DOC NUM

MODIFICATION OF ANESTHESIA PLAN

S.no

date

uhid

Name of pt

SR
NO.
S,No

date

NAME OF
PATIENT

DATE

UNPLANNED VENTILATOR FOLLOWING ANESTHESIA

uhid
Name of pt

PERCENTAGE OF TRA

ADVERSE ANESTHESIA EVENT

S.no

date

uhid

Name of
patient

S NO.

PREPARED BY QM APPROVED BY
DIRECTOR

DATE

ANESTHESIA RELATED

JAIN ENT HOSPITAL

PREPARED BY QM APPROVED BY
DIRECTOR

DOC NUM