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Medicines:
Physical: Ht: ______ Wt.: ______ kg BMI: ______ BP: _____ / _____ T: ______ P: _______ R: _______ O2 Sat: ________
Pre-op Medication:
Post procedure care expected to include ICU
Patient has been informed of the risks, benefits, potential complications and alternatives of anesthesia and has had the opportunity to
ask questions.
Date:_______________ Time: ___________Signature:__________________________________ Physician Number_____________
Post Anesthesia Evaluation:
Patient meets discharge criteria based on review of vital signs, cardiopulmonary status, mental status, pain, nausea & vomiting well
controlled, postoperative hydration adequate
Patient does not meet discharge criteria based on post anesthesia complications: ________________________________________
Plan: _____________________________________________________________
*1-1070* FORM 1-1070 REV. 09/2011 WHITE: Medical Record CANARY & PINK: Anesthesia Page 1 of
1
Send copy to pharmacy_________ (initials)
FORM #3-20 REV. 08/2005 Page 2 of 2