DA Form 7389: Medical Record – Anesthesia | Download PDF

DA Form 7389: Medical Record – Anesthesia | Download PDF – DA Form 7389, officially titled Medical Record – Anesthesia, is a standardized U.S. Army form used to document anesthesia care during surgical and medical procedures. It serves as a critical part of the patient’s official medical record, ensuring accurate tracking of pre-anesthesia evaluations, intraoperative events, medications, vital signs, and post-anesthesia recovery.

Healthcare providers in military treatment facilities (MTFs), including anesthesiologists, Certified Registered Nurse Anesthetists (CRNAs), and anesthesia teams, rely on this form for compliance with Army regulations and high-quality patient care documentation.

What Is DA Form 7389 Used For?

This form replaced earlier versions like SF 517 or OF 517 and is prescribed for use under AR 40-66 (Medical Record Administration and Healthcare Documentation). It provides a structured, graphical record for:

  • Pre-anesthesia patient assessment (physical status, vital signs, labs).
  • Anesthesia techniques and airway management.
  • Continuous monitoring of vital signs, fluids, blood loss, and medications.
  • Intraoperative events and remarks.
  • Post-anesthesia recovery details.

Key Sections Include:

  • Patient identification and procedure details (date, location, surgeons, anesthetists, CPT codes).
  • Physical status (ASA 1-5 or E for emergency).
  • Body weight, hematocrit, initial BP/HR.
  • Anesthetic agents (volatile agents, single-dose drugs, continuous infusions).
  • Ventilation parameters, monitors, and equipment checks.
  • Fluid balance (crystalloid, colloid, blood), estimated blood loss (EBL), urine output.
  • Time-based graphical charting for BP, HR, SpO2, ETCO2, temperature, etc.
  • Remarks section for coded events and drugs.
  • Recovery information (PACU, ICU, or other) and condition at handover.

The form supports detailed, real-time documentation essential for patient safety, continuity of care, medicolegal protection, quality improvement, and audits (especially for controlled substances).

Who Uses DA Form 7389?

  • Active Duty Army, Army National Guard, and U.S. Army Reserve medical personnel.
  • Civilian providers working in Army medical facilities.
  • Anesthesia departments for record-keeping (multiple copies: patient’s record, anesthesia provider, department).

It applies to inpatient, outpatient, and ambulatory procedures requiring anesthesia.

How to Fill Out DA Form 7389? (Step-by-Step Guidance)

  1. Patient Identification — Enter full name, rank/grade, medical facility, date, and procedure location.
  2. Pre-Anesthesia Data — Record physical status, weight, hematocrit, initial vital signs, allergies, and relevant history.
  3. Anesthetic Techniques & Airway — Document general, regional, or combined techniques; detail intubation or block methods in remarks.
  4. Intraoperative Charting — Use the time grid to mark vital signs, agents administered (code single doses with numbers and explain in remarks), fluids, losses, and events (code with letters).
  5. Monitors & Equipment — Check and note all monitors (ECG, SpO2, ETCO2, etc.) and warming devices.
  6. Summary & Recovery — Total fluids, blood loss, urine output; record recovery location and patient condition (BP, HR, SpO2, respiration).
  7. Signatures — Anesthetist and any required reviews.

Tips: Use standard symbols and codes explained in remarks. Ensure legibility for scanning into electronic health records. Electronic versions must mirror the official form.

Always follow AR 40-66 guidelines and local MTF policies for completion and filing.

Download Official DA Form 7389 PDF

Official Download Link (U.S. Army Publishing Directorate):
https://armypubs.army.mil/pub/eforms/DR_a/pdf/A7389.pdf

This is the current FEB 1998 version (still in use as of 2026). Use fillable PDFs from trusted Army or DoD sources for digital completion where allowed.

Importance in Modern Military Healthcare

Accurate anesthesia records like DA Form 7389 support:

  • Patient safety and error prevention.
  • Compliance with DoD health record policies (e.g., DHA-PM 6025.02).
  • Research, education, and performance improvement.
  • Legal and billing documentation (CPT codes).

In hybrid paper-electronic systems, the form integrates with systems like CHCS or AHLTA/ESSENTRIS.

  • AR 40-66: Primary regulation for medical records.
  • OF 517 (older civilian equivalent).
  • Consent forms (OF 522 or equivalent).
  • Other anesthesia monitoring outputs that may be attached.

For the latest guidance, visit official Army Publishing Directorate (armypubs.army.mil) or consult your facility’s Medical Records Department.

Need the form for training, deployment, or MTF use? Download it directly from the official link above and ensure you follow current Army and DoD protocols for medical documentation.