MBALE RRH PRE-ANAESTHETIC ASSESSMENT FORM
Name____________________________________
Age_________
Sex: M / F
IP No: _______________
Planned procedure ____________________________________________Weight______kg Date_______________
History of the presenting complaint:
Pre-existing medical problems:
Surgical history:
Social History:
Smoker? YES/NO
Alchohol: YES/NO
Drugs: YES/NO
Previous anaesthesia (including complications):
Medications:
ALLERGIES:
AIRWAY ASSESSMENT
BREATHING
Mallampati I II III IV
RR_______breaths/min
Mouth opening________ cm
SpO2 _____%
Thyro-mental distance _______cm
Sign(s) of respiratory distress? YES / NO
Loose teeth/dentures?
On Oxygen? YES / NO
YES / NO
Neck movement? NORMAL / RESTRICTED
Recent chest infection? YES / NO
Jaw Protrusion: NORMAL / RESTRICTED
Auscultation:
ANTICIPATED DIFFICULT AIRWAY? YES / NO
CIRCULATION
DISABILITY
BP:
A V P U
Pulse rate:______bpm
GCS: E:
Pulse rhythm:
Blood sugar:
REGULAR / IRREGULAR
Last oral intake:
V:
M:
TOTAL:
/15
Capillary refill: _________s
Extremities: WARM / COLD
EXPOSURE
Heart sounds:
Body Temperature________○C
IV access:
Recent Burns? YES / NO
Active bleeding? YES / NO
Reduced urine output? YES / NO
INVESTIGATIONS
Hb:
Na:
PLT:
K:
WBC:
Other investigations:
Radiology investigations:
Blood group:
Blood available? YES / NO
Department of Anaesthesia & Critical Care. Mbale RRH. v1.0 November 2021
Key patient problems:
ASA 1 2 3 4 5 6 E
ASOS RISK SCORE:
/25
Recommendations prior to surgery:
Anaesthetic Plan:
Further investigations required:
Fasting advice given: advised to fast from _________am/pm
Blood required in theatre: YES/ NO
Other recommendations:
Anaesthetic Consent
-
Discussed risks and benefits of GA
YES/NO
-
Discussed risks and benefits of spinal YES/NO
Planned post-operative destination:
Assessor: Name:___________________________ Job title:_________________ Date/Time of assessment:____________________
Senior review: Name ______________________________________ Job title:____________________________________________
Time/Date of senior review:____________________________ Patient deemed fit for surgery? YES / NO
Other comments:
ASOS RISK SCORE CALCULATOR
Use this table to calculate the ASOS risk score for your patient
Age (years)
ASA
Urgency
Severity
Indication
Specialty
PATIENT SCORE
<5
+3
5 - 17
+1
18 - 29
0
30 - 69
+1
≥70
+3
1
0
2
+2
3
+5
≥4
+8
Elective
0
Urgent
+3
Emergency
+4
Minor
0
Intermediate
+2
Major
+4
Non-communicable disease
0
C-section
-2
Trauma
+1
Infection
+2
Obstetrics/Gynae
-1
Plastics/breast
+1
Urology
+2
ENT
+3
GI, hepato-bilary, cardiothoracic, vascular or neurosurgery
+4
All other types of surgery
0
TOTAL :
/25