Form F-06 Preview

Airway Management / Intubation Note

[HOSPITAL NAME]

Department of Anesthesiology

FORM F-06

Document to Medical Record

Quick Clinical Template

Affix Patient Label Here

Name:

MRN:

DOB:

Airway Device

Endotracheal Tube (ETT) Supraglottic Airway (SGA/LMA) Face Mask Only Tracheostomy

Size

Depth (cm at lips/teeth)

Laryngoscopy & Attempts

Method

Direct Laryngoscopy (DL) Video Laryngoscopy (VL) Awake Fiberoptic

Cormack-Lehane Grade

Grade I Grade II Grade III Grade IV

Number of Attempts

1 2 3+

Intubating Clinician

Adjuncts Used

None Stylet Bougie / Introducer BURP / OELM Magill Forceps Oral/Nasal Airway

Other:

Confirmation of Placement

Positive ETCO₂ (Capnography) - MANDATORY Bilateral Breath Sounds Equal Chest Rise Visualized Through Cords

Complications / Events

None / Uneventful

Desaturation (SpO₂ < 90%) Dental / Lip Trauma Bleeding / Blood in Airway Esophageal Intubation

Details / Action Taken:

If YES, document in patient chart for future anesthetics.

NO YES

Anesthesia Provider Signature

Provider Name (Print) / ID / Stamp

Date & Time

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