Patient (Record Target)
Author
Custodian
Related documents (Pre-operative assessment, Preoperative instruction, Anaesthetic plan, Postoperative assessment) 

Encompassing encounter (SNOMED code saying this is an anaesthesia record, Encounter participants including staff and devices)

Case Setup (This is the equivalent of the old preference card, anaesthetic kardex, was technique)
Anesthetic machine, devices, drug checks
Patient Safety checks 
WHO surgical checklist, recorded as done, or N/A

Case Information, procedure, diagnosis, ASA, height, weight, BMI, current location, source & destination
Pre-medication

Preparation
	Attaching monitoring
	Vascular access procedures
	Regional anaesthetic procedures

GA Technique
	Airway management	
Drugs, fluids and agents
Fluid Balance
Equipment Used
Vital Signs and Physiologicaly monitored variables
Patient Positioning
Intraoperative Events/Notes
Intraoperative tests, investigations and images: Evaluation Procedure 386053000
Procedure actually performed

Postoperative instructions
PACU Arrival Information
Warning for future care/Anaesthesia alerts/Hazard flags


Case Information (Procedure, diagnosis, ASA, height, weight, BMI, current location, source & destination)
Safety checks (anesthetic machine checks, device checks, drug checks)
Operative note
Techniques
Vital signs 
Intraoperative tests, investigations and images
Drugs, fluids and agents
Events 
Postoperative  instructions