PAC + AIR Offline Fallback Record v1.0

1. Visit & Diagnosis

PAC visit type *

Surgery urgency

ASA physical status *

Primary diagnosis & proposed procedure

2. Vital Signs and Physical Examination

Response (alertness)

Height (cm)

Weight (kg)

BMI (kg/m²)

Temperature (°F)

BP systolic (mmHg)

BP diastolic (mmHg)

Pulse rate (bpm)

Respiratory rate (bpm)

SpO2 (%)

Room air / supplemental O2

Blood group & Rh type

Chest auscultation

Other physical examination

3. Allergies

No known allergies Penicillin and related antibiotics allergy history Sulfa drugs allergy history Aspirin, ibuprofen and other NSAIDs allergy history Chemotherapy drugs allergy history Other

4. Co-existing Illness

5. Additional Risk Flags (NSQIP-style factors)

Steroid/immunosuppressant use

Fever/cough/cold (6wk)

Ascites

Sepsis (current)

Ventilator dependent

Disseminated cancer

Dyspnea

Chronic heart failure

Functional status

Current smoker (1y)

Severe COPD

Dialysis

Acute renal failure

6. Medications & Treatment History

Medications taken in last 1 month

Radiotherapy

Chemotherapy

7. Addictions

No addictions to declare Smokeless Tobacco Smoking Cannabis Alcohol Opioid Amphetamine Cocaine Other

8. Airway Assessment

9. Labs

Hematology

Hb (g/dL)

TLC (×10⁹/L)

ANC (×10⁹/L)

Platelets (×10⁹/L)

Coagulation

INR

PT (s)

APTT (s)

Biochemistry

FBS (mg/dL)

RBS (mg/dL)

2hPPBS (mg/dL)

HbA1c (%)

S. Creatinine (mg/dL)

S. Bilirubin, total (mg/dL)

S. Bilirubin, conjugated (mg/dL)

S. Albumin (g/dL)

S. ALT (U/L)

S. AST (U/L)

S. TSH (mIU/L)

S. FT4 (ng/dL)

Cardiopulmonary

NT-proBNP (pg/mL)

ECG findings

Resting echocardiography

Stress ECG

Pulmonary function tests

Chest X-ray / CT thorax

10. Fitness Determination

Fit — normal risk (only selectable when ASA PS I) Fit — elevated risk To be reassessed — pending labs / medication review To be reassessed — after acute illness subsides To be reassessed — after chronic illness improves To be reassessed — after specialist review Provisionally fit — pending compliance with preop advice Unfit for elective major surgery — high risk Other:

Specify if other

11. Preoperative Advice

Do not smoke, not use smokeless tobacco, and not take alcohol No solid food, semi solid food, or drinks for at least 6 hours before surgery No heavy meals for at least 8 hours before surgery Fasted patients: sips of ORS/glucose water hourly, up to 2h before OT Tab. PANTOPRAZOLE 40 mg at 10 PM and 6 AM with water Inj. FERRIC CARBOXYMALTOSE 500 mg/10 mL in 100 mL NS Tab. MULTIVITAMIN, 1 tab once daily for 15 days Incentive spirometry Aerobic exercise Isometric exercise Nutritional augmentation

Medications to CONTINUE through day of surgery

Medications to STOP before / RESTART after surgery

12. Medication Advice Table

Medication	Dose & route	Frequency	Duration

13. Doctor's Notes

Notes

14. Sign-off

Attending doctor name

Attending doctor CC no. / Medical Council Registration No. *

Record timestamp

1. Team & Patient Checks

Anesthesiologist(s)

Anesthesia resident(s)

Surgeon(s)

Preoperative fasting

ASA physical status *

Patient ID verified

Consent checked

2. Clinical Details & Vitals

Response (alertness)

Height (cm)

Weight (kg)

BMI (kg/m²)

Temperature (°F)

BP systolic (mmHg)

BP diastolic (mmHg)

Pulse rate (bpm)

Respiratory rate (bpm)

SpO2 (%)

Room air / supplemental O2

Blood group & Rh type

3. Allergies

No known allergies Penicillin and related antibiotics allergy history Sulfa drugs allergy history Aspirin, ibuprofen and other NSAIDs allergy history Chemotherapy drugs allergy history Other

4. Airway Assessment

5. Surgery and Anesthesia General Info

Surgery urgency category

Position

Anesthesia technique

Anesthesia start

Eye protection

Pressure points protection

Throat pack in

Throat pack out

Tourniquet (site, duration, pressure mmHg)

Proposed procedure

Completed procedure

6. Monitoring

7. Vascular Access

Peripheral IV cannula (size/site)

Central venous catheter placed

Arterial cannula placed

8. Regional / Neuraxial Techniques

Intrathecal (spinal)

Epidural

9. General Anesthesia Procedure

Sequence

Pre-oxygenation done

Basic airway devices

Induction agent

Induction dose

NMBA

NMBA initial dose

NMBA maintenance dose

Laryngoscopy

Advanced airway device

SGA type/size

ETT type

ETT size

Bronchial blocker

ETT introducer

Unanticipated difficult airway (describe)

Maintenance agent

Fresh gas flow

MAC

Breathing system

Ventilation mode

TIVA drugs

One-lung ventilation (details)

Topical airway anesthesia used

10. IV Fluids & Blood Products

Crystalloids / colloids given Blood products given

Other fluids

Additional IV bolus drugs (extra rows)

11. Drugs

IV drug infusions

IV drug boluses

Antibiotics

Glycopyrrolate

Fentanyl

Morphine

Tramadol

Dexamethasone

Ondansetron

Metoclopramide

Mephentermine

Reversal of residual neuromuscular blockade

Neostigmine + Glycopyrrolate

Sugammadex

12. Vitals Flowsheet

Import CSV CSV columns: Time, then any of SpO2/Pulse/ECG/SBP/DBP/MAP/RR/EtCO2/T/AGM/PIP/Pplat/PPV/SVV/CO/BIS/NMT/TEE, Notes

13. Totals

Total crystalloids (mL)

Total colloids (mL)

Total blood products (mL)

Total input (mL)

Estimated blood loss (mL)

Urine output (mL)

Other losses

14. Emergence & Extubation

Pharyngeal suction Extubation and post-oxygenation

Category	Parameter / threshold	Met
Mental status	A/AVPU or V/AVPU
Sustained muscle power	Head lift / tongue protrusion / limb lift / hand grip > 10 s: Yes
Oxygenation	SpO2 ≥ 95%
Spontaneous Ventilation	RR and EtCO2 within normal limits
Airway patency	Cuff leak present
Spontaneous breathing effort	RSBI < 60
Hemodynamics	Vasopressor requirement ≤ 0.1 mcg/kg/min
Temperature	35.5–38.0°C
Safety	Not agitated, no active vomiting or retching, no active bleeding

Extubation readiness

15. Shift-out & Postoperative Orders

Response (AVPU)

Pulse (bpm)

SpO2 (%)

BP systolic (mmHg)

BP diastolic (mmHg)

Respiratory rate (bpm)

Temperature (°F)

Sustained muscle power

Airway

Breathing

Anesthesia end

Anesthesia duration

Shifted to

Postop monitors

Postoperative Orders

Oral feed / NPO

Oxygen therapy

PACU monitoring / transfer

Antibiotics / DVT prophylaxis

Special notes

Postop IV fluid

Analgesia: Paracetamol

Analgesia: Tramadol

No opioid × 20h

Fentanyl NCA

Fentanyl IV PCA

Pantoprazole (stress ulcer prophylaxis)

Ondansetron

Metoclopramide

Continuous epidural infusion (auto-summary from Section 8)

Continuous nerve block infusion (auto-summary from Section 8)

Other orders

16. Sign-off

Attending anesthesiologist name

Attending doctor CC no. / Medical Council Registration No. *

Record timestamp

Notepad-compatible text output

Hematology

Coagulation

Biochemistry

Cardiopulmonary

IV drug boluses

Reversal of residual neuromuscular blockade

Postoperative Orders

Info

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