Pre-Anaesthesia Checklist
Name
First Name
Last Name
Patient Number (MRN)
Has anything significant been identified in the history and/or clinical examination?
Please Select
Yes
No
If yes, then explain exactly what was identified
Do any abnormalities warrant further investigation?
Please Select
Yes
No
If yes, then which specific investigations need to be requested
Can any abnormalities be stabilised prior to anaesthesia?
Please Select
Yes
No
What complications are anticipated during anaesthesia?
How can these complications be managed?
Would the patient benefit from premedication?
Please Select
Yes
No
How will any pain associated with the procedure be managed?
How will anaesthesia be induced & maintained?
How will the patient be monitored?
How will the patient’s body temperature be maintained?
How will the patient be managed in the post-anaesthetic period?
Are the required facilities, personnel & medications available?
Please Select
Yes
No
If not, then list what or who is currently unavailable and whether it is appropriate to proceed with the surgery.
Submit
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