Form F-02 Preview

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[HOSPITAL NAME]

Department of Anesthesiology

FORM F-02

Document to Medical Record

Short Addendum to Pre-Anesthesia Assessment

Affix Patient Label Here

Name:

MRN:

DOB:

Planned Surgical Procedure

Surgeon / Proceduralist

Health Status Update

NO CHANGES since initial pre-anesthesia assessment CHANGES NOTED (Document details below)

Description of Changes (New symptoms, recent illnesses, test results, physical exam findings):

Updated Vitals (Day of Surgery)

BP (mmHg)

Heart Rate

Resp Rate

SpO₂ (%)

Temp (°C)

Fasting Status & Medications

Fasting (NPO) Compliance

NPO Confirmed (Yes) NPO Violated (No)

Time of last solid:

Time of last clear liq:

Last Medications Taken (Morning of Surgery)

Time:

Updated Anesthesia Plan

Plan REMAINS THE SAME as original assessment Plan UPDATED (Document details below)

New Plan / Specific Instructions / Mitigated Risks (e.g. RSI plan, revised block plan):

Anesthesia Provider Signature

Provider Name (Print) / ID / Stamp

Date & Time

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