CRNA Record Review Tool
ANESTHESIA RECORD REVIEW
1.Preoperative evaluation
completed/reviewed including:
Diagnosis/procedure documented
NPO Status documented
Pertinent lab and preoperative vital
signs documentation
Pertinent medical history
documented
Assessment of lung and heart
auscultation: assessment of airway
with documented Mallampati score
Review of Patient
medications/allergies
Documentation of Beta Blocker
administration
Documentation of plan of care
Documentation of risks and benefits
discussed with patient
Documentation of signature, dated
and timed
Documentation of ASA status
2. Review of Anesthesia Record
including documentation of:
Date of procedure
Preoperative VS, weight in KG, ASA
status, allergies
Type of Anesthetic provided
Blocks provided including: type of
block, medication used, site, use as
primary anesthetic or post-op pain
management
Appropriate intubation
documentation—checklist or
narrative
Appropriate positioning
documentation
Vital signs documented a minimum
of every 5 minutes including
temperature (as appropriate)
Medications given including dose
and timing
Antibiotics given per SCIP protocols
Perioperative temperature
management devices used
COMPLETED
NOT
COMPLETED
COMMENTS
CRNA Record Review Tool
ANESTHESIA RECORD REVIEW
COMPLETED
NOT
COMPLETED
COMMENTS
YES
No
COMMENTS
ETCO2, Ventilation method
including vent settings and PIP (as
needed)
Appropriate monitoring devices
used
IV sites, fluids given and totals at
end of case (including drips that are
infused)
Procedure and Post-operative
diagnosis
Signature
Surgeon
Anesthesia start and end times,
procedure start and end times
Post operative disposition
Postoperative Vital signs
3. Postoperative Evaluation
documentation to include:
Patient assessment
Narrative assessment as needed
Patient ‘signed out’ per anesthesia
policy
4. Outcomes
Excellent provision of care
No adverse outcomes
Minor adverse outcomes
Significant adverse outcome
CRNA Reviewed:
Date of record review:
Patient Initials/MR Number of records reviewed:
Number of records reviewed:
____Based on the medical records I reviewed, I assess that the care provided meets the current national
standards.
____Based on the medical records I reviewed, I have the following comments/recommendations related
to the practice of this peer:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Signature and Credentials of Peer Reviewer: