Anesthesia and Operative (A&O) record
The Anesthesia and Operative (A&O) record is a legal document that records
each anesthetic procedure. THE RECORD MUST BE SIGNED BY THE ATTENDING
ANESTHESIOLOGIST PRESENT AT INDUCTION AND EMERGENCE. IN ADDITION, ALL TIMES
(ANESTHESIA START, ETC.) MUST BE COMPLETELY FILLED OUT, INCLUDING TRANSFERS. The
A&O Record becomes a part of the patient’s permanent chart and should describe
the management of the anesthetic procedure as completely and accurately as
possible. The following data must be recorded on the A&O Record immediately:
Patient’s name
Hospital number
Date and place of service
Patient’s age and ASA physical status
Diagnosis and procedure
Attending/assisting surgeons
Attending/assisting anesthesia personnel
Beginning/ending/transfer times for surgery and anesthesia (using 24 hour clock
to exact minute)
Pertinent events occurring during the induction of, maintenance of, and
emergence from anesthesia
Dosage and duration of all anesthetic agents, other drugs, intravenous fluids,
and blood or blood
components administered
Preoperative medication
Patient’s condition and vital signs on arrival at the recovery room
Routine Monitoring in the Operating Room:
During the anesthetic period in the OR, the following will be routinely
monitored and recorded at specified intervals. Other parameters may be
monitored and recorded as indicated.
Pulse (q 5 mins)
Blood pressure (q 5 mins)
Respiration
Breath and heart sounds via precordial or esophageal stethoscope
EKG rhythm (continuously)
Pulse oximetry (q 15 mins)
End-tidal COČ if the patient is intubated or being ventilated by mask or LMA
(q 15 mins)
Temperature in patients considered at risk for hypo or hyperthermia
Exhaled tidal volume on intubated patients or on patients ventilated by mask
or LMA
