Assessment
The assessment of the patient is documented with details of the assessor (Fig 1) as well as basic vital signs (Fig 2).
Intra-operative records from previous hospital admissions may indicate prior problems with anaesthesia:
- Family history of problems
- Potential airway concerns
- Evaluation of teeth (caps/crowns/loose teeth/false teeth)
The medical assessment that takes place will include the checks listed here (Fig 3).
The chart may also contain a record of the discussion with the patient: what type of anaesthetic is proposed, and what the risks are.
Fig 1 Assessor's details
Fig 2 Vital signs must be recorded
Fig 3 The results of checks carried out are documented on the chart