This customizable document, Pre and Post Anesthesia Evaluation Form, is taken from MCN Healthcare’s Outpatient Surgery and Ambulatory Services Policy and Procedure Manual. For more than 20 years, MCN has been the health care industry’s leading provider of policy and procedure templates, forms, competencies and other compliance tools.

MCN’s templates save you time, money and resources, rather than developing healthcare policy and procedure manuals from scratch.

Here is some sample content from Pre and Post Anesthesia Evaluation Form:

	PRE AND POST ANESTHESIA EVALUATION Patient Name: PATIENT HISTORY Proposed operation: Cardiac: Comments: Respiratory: Other: Endocrine: Other: Liver: Other: Neurological: Other: Other Diseases: Drug or Alcohol use: Medications/Herbal medications, supplements: Allergies: Previous Surgery and Anesthesia: regional through general ? No anesthetic complications ? Family history of anesthetic complications: ? Inpatient PHYSICAL EXAMINATION Cardiac: Other: Lungs: Other: Level of Consciousness: Airway: Chin/Tongue: Teeth: ? Possible intubation problems: Other physical or...
Second excerpt:
	...taken today: ? NPO or time of last oral intake B/P ANESTHETIC PLAN ASA Class: Anesthetic plan: Anesthetic plan, risks and alternatives explained to patient If not explained to patient, give reason: Patient appears to understand and accept the anesthetic plan and possible risks: Comments: Signature: POST ANESTHESIA NOTES Patient's condition on arrival in PACU B/P Level of consciousness: Respirations: Comments: Signature: NOTE AFTER RECOVERY FROM ANESTHESIA Problems,...