# Blank anesthesia case-discussion template

Download first and use only in a hospital-approved clinical system. Do not enter patient data into Sites or a general chat.

## Blank template — use only in the approved clinical system

### Case and source reliability

- Procedure, indication, position, estimated duration, anticipated blood loss and special surgical requirements.
- Clinical context and urgency; relevant demographics and measured height/weight as appropriate within the approved system.
- Source and recency of information; unresolved discrepancies and records still needed.

### History

- Prior anesthesia: airway difficulty, adverse reactions, PONV, awareness concerns, neuromuscular-blocker issues and family history relevant to anesthesia.
- Cardiovascular: symptoms, functional capacity, diagnoses, devices, relevant testing and current stability.
- Pulmonary/sleep: respiratory disease, recent illness, OSA and usual therapy, smoking/exposure history.
- Neurologic, renal, hepatic, endocrine/metabolic, hematologic and other relevant conditions.
- Surgical history; medications including anticoagulants, diabetes agents and supplements; allergies with reaction details.
- Fasting history, reflux/aspiration concerns and other factors needing individualized assessment.

### Examination and investigations

- Airway and dentition; mouth opening, neck movement/constraints, prior records and predicted ventilation/intubation concerns.
- Relevant examination and vital signs; available labs/tests with dates and clinical interpretation.
- ASA physical status for discussion; additional risk tools only where indicated and correctly applied.
- What still requires an in-person assessment or confirmation?

### Proposed plan for discussion

- Anesthetic technique and rationale; alternatives to discuss.
- Oxygenation, airway approach, backup and extubation considerations.
- Monitoring, vascular access, positioning and temperature strategy.
- Induction/maintenance/analgesia/antiemetic/neuromuscular management considerations; drugs and doses confirmed in the approved clinical workflow by the supervising clinician.
- Fluids/blood considerations, relevant preparation and anticipated physiologic challenges.
- Emergence, postoperative disposition, pain plan and handoff priorities.
- Three highest-priority questions for the resident.

### Concise presentation skeleton

“This is a patient scheduled for [procedure and indication]. The main anesthesia-relevant issues are [three priorities]. Prior anesthesia/airway history shows [key facts], with [missing information] still to confirm. My proposed approach for discussion is [technique, airway, monitoring/access, key concerns and postoperative plan]. I would especially like to review [questions].”

This template is a discussion aid; it does not establish consent, orders, documentation completeness or approval of a plan.