DA Form 7389 "Medical Record - Anesthesia"

What Is DA Form 7389?

This is a military form that was released by the U.S. Department of the Army (DA) on February 1, 1998. The form, often mistakenly referred to as the DD Form 7389, is a military form used by and within the U.S. Army. As of today, no separate instructions for the form are provided by the DA.

Form Details:

  • A 3-page document available for download in PDF;
  • The latest version available from the Army Publishing Directorate;
  • Editable, free, and easy to use;

Download an up-to-date fillable DA Form 7389 down below in PDF format or browse hundreds of other DA Forms stored in our online database.

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Download DA Form 7389 "Medical Record - Anesthesia"

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MEDICAL RECORD - ANESTHESIA
For use of this form, see AR 40-66; the proponent agency is the OTSG
DRUG
(Units)
TOTALS
TOTAL EBL
(
)
(
)
(
)
TOTAL URINE
)
(
(
)
(
)
VOLAT
% del
FLUIDS - SUMMARY
AGENT
CRYSTALLOID-
% e.t.
L/Min
AIR
COLLOID-
N2O
L/Min
L/Min
O2
BLOOD-
SINGLE DOSE DRUGS-MARK ON GRID
WITH NUMBERS & ENTER IN REMARKS
LINE site
Warmed
REMARKS
Warmed
Code drugs with numbers,
events with lettters
Warmed
Warmed
EST BLOOD LOSS
LOSSES
URINE -
-
PHYS STATUS
TIME
1 2 3 4 5 E
SYMBOLS:
BODY WEIGHT:
220
KG
BP by cuff
200
LB
HEMATOCRIT:
180
Heart rate
160
INITIAL DATA:
Resp rate
140
BP-
120
/
BR
HR-
100
(transduced)
80
EQUIP CHECK
OK?-
60
TOURNIQUET
T
PATIENT RECHECK
40
OK for
X-X
PROCEDURE?
ANES-
20
PROC-
TIME-
VT - ml
f - breaths/min
Peak inf pres / PEEP
MODE - S(pon), A(ssist), C(on)
RECOVERY AT
ET CO2 (torr)
BP/Auto Cuff
(Specify)
PACU ICU
FlO2 (Frac or %)
BP/oth
OTHER
SpO2
(%)
ART line
CONDITION:
Steth- PC/ES
ECG
RESP-
SpO2-
Gas analyzer
TEMP-site
BP-
HR-
N-M Block (T/4)
ANESTHESIA / PROCEDURE
TIMES
Start
Room
End
Warming blkt
Conv warmer
Ready Begin
End
EVENTS
Mark with letters & symbols,
explain under REMARKS
Position
PROCEDURES and CPT Codes:
ANESTHETIC TECHNIQUES: Describe block technique under Remarks
PATIENT IDENTIFICATION:
Typed or written entries: Name, Grade/Rate,
AIRWAY MANAGEMENT: Intubation route, blade, technique, comments
Medical facility
SURGEONS:
PROCEDURE
LOCATION:
DATE:
ANESTHETISTS:
PAGE
OF
DA FORM 7389, FEB 1998
COPY 1 - PATIENT'S MEDICAL RECORD
APD LC v1.00
MEDICAL RECORD - ANESTHESIA
For use of this form, see AR 40-66; the proponent agency is the OTSG
DRUG
(Units)
TOTALS
TOTAL EBL
(
)
(
)
(
)
TOTAL URINE
)
(
(
)
(
)
VOLAT
% del
FLUIDS - SUMMARY
AGENT
CRYSTALLOID-
% e.t.
L/Min
AIR
COLLOID-
N2O
L/Min
L/Min
O2
BLOOD-
SINGLE DOSE DRUGS-MARK ON GRID
WITH NUMBERS & ENTER IN REMARKS
LINE site
Warmed
REMARKS
Warmed
Code drugs with numbers,
events with lettters
Warmed
Warmed
EST BLOOD LOSS
LOSSES
URINE -
-
PHYS STATUS
TIME
1 2 3 4 5 E
SYMBOLS:
BODY WEIGHT:
220
KG
BP by cuff
200
LB
HEMATOCRIT:
180
Heart rate
160
INITIAL DATA:
Resp rate
140
BP-
120
/
BR
HR-
100
(transduced)
80
EQUIP CHECK
OK?-
60
TOURNIQUET
T
PATIENT RECHECK
40
OK for
X-X
PROCEDURE?
ANES-
20
PROC-
TIME-
VT - ml
f - breaths/min
Peak inf pres / PEEP
MODE - S(pon), A(ssist), C(on)
RECOVERY AT
ET CO2 (torr)
BP/Auto Cuff
(Specify)
PACU ICU
FlO2 (Frac or %)
BP/oth
OTHER
SpO2
(%)
ART line
CONDITION:
Steth- PC/ES
ECG
RESP-
SpO2-
Gas analyzer
TEMP-site
BP-
HR-
N-M Block (T/4)
ANESTHESIA / PROCEDURE
TIMES
Start
Room
End
Warming blkt
Conv warmer
Ready Begin
End
EVENTS
Mark with letters & symbols,
explain under REMARKS
Position
PROCEDURES and CPT Codes:
ANESTHETIC TECHNIQUES: Describe block technique under Remarks
PATIENT IDENTIFICATION:
Typed or written entries: Name, Grade/Rate,
AIRWAY MANAGEMENT: Intubation route, blade, technique, comments
Medical facility
SURGEONS:
PROCEDURE
LOCATION:
DATE:
ANESTHETISTS:
PAGE
OF
DA FORM 7389, FEB 1998
COPY 1 - PATIENT'S MEDICAL RECORD
APD LC v1.00
MEDICAL RECORD - ANESTHESIA
For use of this form, see AR 40-66; the proponent agency is the OTSG
DRUG
(Units)
TOTALS
TOTAL EBL
(
)
(
)
(
)
TOTAL URINE
)
(
(
)
(
)
VOLAT
% del
FLUIDS - SUMMARY
AGENT
CRYSTALLOID-
% e.t.
L/Min
AIR
COLLOID-
N2O
L/Min
L/Min
O2
BLOOD-
SINGLE DOSE DRUGS-MARK ON GRID
WITH NUMBERS & ENTER IN REMARKS
LINE site
Warmed
REMARKS
Warmed
Code drugs with numbers,
events with lettters
Warmed
Warmed
EST BLOOD LOSS
LOSSES
URINE -
-
PHYS STATUS
TIME
1 2 3 4 5 E
SYMBOLS:
BODY WEIGHT:
220
KG
BP by cuff
200
LB
HEMATOCRIT:
180
Heart rate
160
INITIAL DATA:
Resp rate
140
BP-
120
/
BR
HR-
100
(transduced)
80
EQUIP CHECK
OK?-
60
TOURNIQUET
T
PATIENT RECHECK
40
OK for
X-X
PROCEDURE?
ANES-
20
PROC-
TIME-
VT - ml
f - breaths/min
Peak inf pres / PEEP
MODE - S(pon), A(ssist), C(on)
RECOVERY AT
ET CO2 (torr)
BP/Auto Cuff
(Specify)
PACU ICU
FlO2 (Frac or %)
BP/oth
OTHER
SpO2
(%)
ART line
CONDITION:
Steth- PC/ES
ECG
RESP-
SpO2-
Gas analyzer
TEMP-site
BP-
HR-
N-M Block (T/4)
ANESTHESIA / PROCEDURE
TIMES
Start
Room
End
Warming blkt
Conv warmer
Ready Begin
End
EVENTS
Mark with letters & symbols,
explain under REMARKS
Position
PROCEDURES and CPT Codes:
ANESTHETIC TECHNIQUES: Describe block technique under Remarks
PATIENT IDENTIFICATION:
Typed or written entries: Name, Grade/Rate,
AIRWAY MANAGEMENT: Intubation route, blade, technique, comments
Medical facility
SURGEONS:
PROCEDURE
LOCATION:
DATE:
ANESTHETISTS:
PAGE
OF
DA FORM 7389, FEB 1998
COPY 2 - ANESTHESIA PROVIDER
APD LC v1.00
MEDICAL RECORD - ANESTHESIA
For use of this form, see AR 40-66; the proponent agency is the OTSG
DRUG
(Units)
TOTALS
TOTAL EBL
(
)
(
)
(
)
TOTAL URINE
)
(
(
)
(
)
VOLAT
% del
FLUIDS - SUMMARY
AGENT
CRYSTALLOID-
% e.t.
L/Min
AIR
COLLOID-
N2O
L/Min
L/Min
O2
BLOOD-
SINGLE DOSE DRUGS-MARK ON GRID
WITH NUMBERS & ENTER IN REMARKS
LINE site
Warmed
REMARKS
Warmed
Code drugs with numbers,
events with lettters
Warmed
Warmed
EST BLOOD LOSS
LOSSES
URINE -
-
PHYS STATUS
TIME
1 2 3 4 5 E
SYMBOLS:
BODY WEIGHT:
220
KG
BP by cuff
200
LB
HEMATOCRIT:
180
Heart rate
160
INITIAL DATA:
Resp rate
140
BP-
120
/
BR
HR-
100
(transduced)
80
EQUIP CHECK
OK?-
60
TOURNIQUET
T
PATIENT RECHECK
40
OK for
X-X
PROCEDURE?
ANES-
20
PROC-
TIME-
VT - ml
f - breaths/min
Peak inf pres / PEEP
MODE - S(pon), A(ssist), C(on)
RECOVERY AT
ET CO2 (torr)
BP/Auto Cuff
(Specify)
PACU ICU
FlO2 (Frac or %)
BP/oth
OTHER
SpO2
(%)
ART line
CONDITION:
Steth- PC/ES
ECG
RESP-
SpO2-
Gas analyzer
TEMP-site
BP-
HR-
N-M Block (T/4)
ANESTHESIA / PROCEDURE
TIMES
Start
Room
End
Warming blkt
Conv warmer
Ready Begin
End
EVENTS
Mark with letters & symbols,
explain under REMARKS
Position
PROCEDURES and CPT Codes:
ANESTHETIC TECHNIQUES: Describe block technique under Remarks
PATIENT IDENTIFICATION:
Typed or written entries: Name, Grade/Rate,
AIRWAY MANAGEMENT: Intubation route, blade, technique, comments
Medical facility
SURGEONS:
PROCEDURE
LOCATION:
DATE:
ANESTHETISTS:
PAGE
OF
DA FORM 7389, FEB 1998
COPY 3 - ANESTHESIA DEPARTMENT
APD LC v1.00
Page of 3