Anesthesia Logbook v8.2

1 Patient & Case Info

Patient Name / Code *

Hospital *

Date & Time *

Sex

Weight (kg)

Height (cm)

IBW (kg)

2 Patient History

A. Chronic Medical Diseases:

HTN

DM

Asthma

Heart Disease

Kidney Disease

Other

Specify Other Chronic Disease

B. Anesthesia History:

Previous Anesthesia Complications

Difficult Intubation History

Allergies to Anesthetics

Family History of Anesthesia Problems

Anesthesia History Details

C. Previous Surgical History:

D. Social History:

Smoking

No

Yes

Former

Pack-Years / Details

Alcohol

No

Yes

Former

Frequency / Details

E. Obstetric History (If OB Case):

G (Gravida)

P (Para)

A (Abortions)

Previous C/S

Previous C/S = Number of previous cesarean sections (important for anesthesia planning)

3 Pre-Op Assessment

Mallampati

2–3–3 Test

Fasting Status:

Full Stomach:

Yes

No

Solids:

≥ 8 hours

< 8 hours

Clear Fluids:

≥ 2 hours

< 2 hours

4 Basic Investigations

Hb

Platelets

INR

Blood Type

Add PT

PT (seconds)

Virology:

Negative

Positive

HIV

HBV

HCV

5 ECG

Not Done

Normal

Abnormal

ECG Interpretation / Abnormal Findings

6 Chest X-Ray (CXR)

Not Done

Normal

Abnormal

CXR Interpretation / Abnormal Findings

7 Echocardiography (Echo)

Not Done

Normal

Abnormal

Echo Interpretation / Abnormal Findings

8 ASA Physical Status Classification

ASA Classification: Assessment of patient's physical status and perioperative risk. This is an independent authority section for proper risk stratification.

ASA I

Normal healthy patient

ASA II

Mild systemic disease

ASA III

Severe systemic disease

ASA IV

Severe systemic disease (constant threat to life)

ASA V

Moribund patient (not expected to survive without operation)

ASA VI

Brain-dead organ donor

Emergency Case (E)

Check if this is an emergency procedure

9 Surgery Type & Procedure

Name of Procedure

Surgery Type:

Specify Other Surgery Type

⏱️ Levels of Surgical Urgency:

Elective

Scheduled surgery, can be delayed without harm

Semi-Elective

Should be done soon but not immediately (within days to weeks)

Urgent

Requires surgery within hours (within 24 hours)

Emergency

Life-threatening, requires immediate surgery

11 Airway Device

Mask

LMA

ETT

Other

Specify Other Airway Device

12 Anesthesia Type

GA

Spinal

Epidural

Sedation

Regional Block

Other

Specify Other Anesthesia Type

13 Recovery

Monitored Well

Sent To

Complications:

None

Pain

PONV

Hypotension

Other

Specify Other Complication

14 Clinical Notes

Additional Notes / Medico-Legal Documentation

Dr. Amir Fadhel

Anesthesia Logbook

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About the Author

Dr. Amir Fadhel, MBChB, FICMS–AIC (Iraq)

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Dr. Amir Fadhel

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