INSTITUTO MEXICANO DEL SEGURO SOCIAL

DIRECCIÓN DE PRESTACIONES MÉDICAS

UMAE HOSPITAL DE ESPECIALIDADES CMNO
DIRECCION MEDICA, DIVISION DE CIRUGIA
DEPARTAMENTO DE ANESTESIOLOGIA
BELISARIO DOMINGUEZ No. 1000, Col Independencia.CP 44320, Guadalajara, Jalisco

NOTA DE VALORACION PREVIO PROCEDIMIENTO ANESTESICO

FECHA:__________________
NOMBRE:______________________________________________________________ NUMERO SEGURO SOCIAL ________________________
EDAD:_______ SEXO:___________ PESO:_________ TALLA:_______ SUPERFICIE CORPORAL_______
GRUPO SANGUINEO ___________
Diagnóstico:______________________________________________________________
CX.Programada:__________________________________________________________

ANTECEDENTES: EXPLORACION FISICA

Tabaquismo SI____ NO_____ Ayuno SI__NO___ Hrs._____________
___________________________________________________________ Prótesis Dentales SI__NO___
Alcoholismo SI_____ NO____ Móviles______ Fijas___ Dientes Flojos_____
___________________________________________________________ Marcapasos SI__NO___ __________
Adicciones SI_____ NO____ PRESION________ FRECUENCIA CARDIACA______
___________________________________________________________ SATURACION DE OXIGENO_______FRECUENCIA
Transfusiones SI_____NO_____ RESPIRATORIA_______TEMPERATURA__________
___________________________________________________________ Tegumentos_________________________________________
Quirúrgicos SI____NO_____ Hidratación_________________________________________
___________________________________________________________ Glasgow______ Conciencia__________________________
___________________________________________________________ Mallampati_____ Distancia Tiro-Menton ___________
Anestésicos SI____NO_____ Cuello________________________________________________
___________________________________________________________ Torax________________________________________________
___________________________________________________________ Abdomen____________________________________________
Alérgicos SI____NO____ Extremidades_______________________________________
___________________________________________________________ LABORATORIO
___________________________________________________________ Hemoglobina______ Hematocrito_____ Plaquetas _____
ENFERMEDADES: Tiempo Protombina_________Tiempo Parcial de
Cardiopatía SI____NO____ Tromboplastina ___________ INR________ Cloro ______
___________________________________________________________ Sodio ______ Potasio______ Urea_____ Creatinina_______
Diabetes SI_____NO____ ELECTRO:_________________________________________________
___________________________________________________________ _____________________________________________________________
HIPERTENSION SI____NO_____ PLACA DE TORAX________________________________________
___________________________________________________________ Otros__________________________________________________
Convulsiones SI_____NO_____
___________________________________________________________ COMENTARIOS_______________________________________
Asma SI_____NO_____ _________________________________________________________
___________________________________________________________ _________________________________________________________
Otras SI_____NO_____ _________________________________________________________
___________________________________________________________ _________________________________________________________
Medicación:______________________________________________ _________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
RIESGO QUIRURGICO ANESTESICO: __________ASA:______________

PLAN ANESTESICO:__________________________________________________________________________________________________

Dr.(a)__________________________________MB MATRICULA ._________________ DR. R___A ____________________

NORMA Oficial Mexicana NOM-006-SSA3-2011, Para la práctica de la anestesiología

 INSTITUTO MEXICANO DEL SEGURO SOCIAL
DIRECCIÓN DE PRESTACIONES MÉDICAS
UMAE HOSPITAL DE ESPECIALIDADES CMNO
DIRECCION MEDICA, DIVISION DE CIRUGIA
DEPARTAMENTO DE ANESTESIOLOGIA
BELISARIO DOMINGUEZ No. 1000, Col Independencia.CP 44320, Guadalajara, Jalisco
NOTA TRANSANESTESICA
TECNICA ANESTESICA UTILIZADA: _______________________________DESCRIPCION DE LA TECNICA DE ANESTESICA
UTILIZADA:________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________
TENICA DE ANESTESIA GENERAL: PREINDUCCION:_____________________________________________________________
INDUCCION:____________________________________________________RELAJANTE:_____________________________________________________________
INTUBACION Si_____ NO___ Oral ____ Nasal _____ MASCARILLA LARINGEA ____ No._____
COMPLICACIONES_________________________________________________________________________________________________________________________
MONITOREO: ELECTROCARDIOGRAMA____PRESION ARETRIAL ____CAPNOGRAFIA ____SATURACION DE OXIGENO ___
INDICE BIESPECTRAL _____PRESION ARTERIAL INVASIVA _____PESION VENOSA CENTRAL_____
LIQUIDOS: INGRESOS_________ EGRESOS_________BALANCE__________ SANGRADO________ URESIS__________
EMERSION:_________________________________________________________________________________________________________________________________
EXTUBACION:______________________________________________________________________________________________________________________________
PASA A: RECUPERACION___ UCI ___ INTERMEDIOS___ALDRETE______GLASGOW_______PRESION ARTERERIAL
____________SATURACION DE OXIGENO_______FRECUENCIA CARDIACA______FRECUENCIA RESPIRATORIA______
TEMPERATURA_____ DR.______________________________MB. MATRICULA________________ RESIDENTE________________________________
ENLACE DE TURNO-NOTA DE ENTREGA-RECEPCION ---HORA_________
______________________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________________
ENTREGA DR__________________________MB MATRICULA__________ RECIBE DR______________________MB MATRICULA_________________
NOTA POSTANESTESICA
ANESTESIA ADMINISTRADA____________________________________________ DURACION ANESTESIA:___________________
MEDICAMENTOS:__________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________
COMPLICACIONES:SI___NO____CUALES:____________________________________________________________________________________
LIQUIDOS: Hartman_________Sol.Fis.0.9%_________Almidon_________Gluc.5%________Otros_________________
TRANSFUSION: PAQUETE GLOBULAR _______PLASMA_______PLAQUETAS______CRIOS______BALANCE_________SANGRADO_______
URESIS________ GASTO URINARIO ___ml/Kg/hr PLAN DE MANEJO: Pasa de Recuperación_____ UCI_____ Aldrete_____
GLASGOW________PRESION _____ ARTERIAL MEDIA ______ SATURACION _______FRECUENCIA CARDIACA ______ FRECUENCIA
RESPIRATORIA_________ DR.________________________MB MATRICULA______________ RESIDENTE ______________________
NOTA DE RECUPERACION : HORA________PRESION ______ FRECUENCIA CARDIACA ______SATURACION________FRECUENCIA
RESPIRATORIA __________ TEMPERATURA___________ ALDRETE_____GLASGOW_____ESCALA DE DOLOR _____________
MEDICACION___________________________________________________________________________________
______________________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________
NOTA DE ALTA DE RECUPERACION: HORA: __________ PASA A
______________________________________________________________________________________________________________________________________________
PRESION _______FRECUENCIA CARDIACA _____ FRECUENCIA RESPIRATORIA __________ SATURACION______ ALDRETE____
GLASGOW_____EVA____ OBSERVACIONES________________________________________________________________________________________________
DR.__________________________MB MATRICULA_____________ RESIDENTE ______________