Case Info Anesthesia type Date of Service Provider ID/Provider NPI Patient ID CRNA ID ASA Physical Status Additional provider Co-morbidities: Arrhythmia ☐ Reactive Airway disease ☐ Diabetes ☐ Latex Allergy ☐ Trach/Laryn/Bronch ☐ ☐ Single Ventricle ☐ ☐ GERD Chromo Anomaly Malacia CHF ☐ Difficult Airway ☐ Hypertension ☐ H/O of ED ☐ Cyanotic CHD ☐ Cystic Fibrosis ☐ Hemaglobinopathy ☐ Obesity ☐ Acyanotic CHD VC Dysfunction disease/failure Premi < 37 weeks ☐ ☐ ☐ ☐ Pulmonary HTN ☐ Pneumonia ☐ Renal Disease/failure ☐ Downs ☐ Disease ☐ BPD/CLD ☐ Hematologic ☐ Seizures ☐ Cardiomyopathy OSA Endocrine other Developmental Delay ☐ ☐ ☐ ☐ Metabolic Intracranial ☐ ☐ ☐ Spina Bifida ☐ Cerebral Palsy disorder Hemorrhage Failure to thrive ☐ H/O SIDS ☐ Hydrocephalus ☐ Other ☐ ☐ ☐ NO ADVERSE Death Airway Trauma Equipment/Device Peripheral Neurologic Unplanned ☐ ☐ ☐ ☐ Failure/Malfunction Deficit after Regional Ventilation Anesthesia Anaphylaxis Fall Pneumothorax Vascular Injury ☐ ☐ ☐ ☐ Arrhythmia Failed Intubation Postdural Puncture Wrong Patient ☐ ☐ ☐ ☐ Headache Aspiration High Spinal or Pulmonary Edema Wrong Site Surgery ☐ ☐ ☐ ☐ Epidural Awareness Inadvertent Reintubation ☐ ☐ ☐ ☐ Hypothermia Bronchospasm Inadequate Pain Respiratory Arrest ☐ ☐ ☐ ☐ Control Burn Injury Inadequate reversal Seizure ☐ ☐ ☐ ☐ of neuromuscular block Cardiac Arrest Malignant Transfusion Reaction ☐ ☐ ☐ ☐ Hyperthermia Case Cancelled Medication Error Unplanned Dural ☐ ☐ ☐ ☐ Puncture Corneal Injury Myocardial Infarction Unplanned Hospital ☐ ☐ ☐ ☐ Admission Delirium Perioperative Visual Unplanned ICU ☐ ☐ ☐ Loss Admission
Case Info Anesthesia type Date of Service Provider ID/Provider NPI Patient ID CRNA ID ASA Physical Status Additional provider Co-morbidities: Arrhythmia ☐ Reactive Airway disease ☐ Diabetes ☐ Latex Allergy ☐ Single Ventricle ☐ Trach/Laryn/Bronch Malacia ☐ GERD ☐ Chromo Anomaly ☐ CHF ☐ Difficult Airway ☐ Hypertension ☐ H/O of ED ☐ Cyanotic CHD ☐ Cystic Fibrosis ☐ Hemaglobinopathy ☐ Obesity ☐ Acyanotic CHD ☐ VC Dysfunction ☐ disease/failure ☐ Premi < 37 weeks ☐ Pulmonary HTN ☐ Pneumonia ☐ Renal Disease/failure ☐ Downs ☐ Disease ☐ BPD/CLD ☐ Hematologic ☐ Seizures ☐ Cardiomyopathy ☐ OSA ☐ Endocrine other ☐ Developmental Delay ☐ Metabolic disorder ☐ Spina Bifida ☐ Cerebral Palsy ☐ Intracranial Hemorrhage ☐ Failure to thrive ☐ H/O SIDS ☐ Hydrocephalus ☐ Other ☐ NO ADVERSE ☐ Death ☐ Airway Trauma ☐ Equipment/Device Failure/Malfunction ☐ Peripheral Neurologic Deficit after Regional Anesthesia ☐ Unplanned Ventilation ☐ Anaphylaxis ☐ Fall ☐ Pneumothorax ☐ Vascular Injury ☐ Arrhythmia ☐ Failed Intubation ☐ Postdural Puncture Headache ☐ Wrong Patient ☐ Aspiration ☐ High Spinal or Epidural ☐ Pulmonary Edema ☐ Wrong Site Surgery ☐ Awareness ☐ Inadvertent Hypothermia ☐ Reintubation ☐ ☐ Bronchospasm ☐ Inadequate Pain Control ☐ Respiratory Arrest ☐ ☐ Burn Injury ☐ Inadequate reversal of neuromuscular block ☐ Seizure ☐ ☐ Cardiac Arrest ☐ Malignant Hyperthermia ☐ Transfusion Reaction ☐ ☐ Case Cancelled ☐ Medication Error ☐ Unplanned Dural Puncture ☐ ☐ Corneal Injury ☐ Myocardial Infarction ☐ Unplanned Hospital Admission ☐ ☐ Delirium ☐ Perioperative Visual Loss ☐ Unplanned ICU Admission ☐