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Patient Follow Up Record
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Procedure:
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Anesthesiologist/CRNA
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Patient Home Phone:
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Patient Cell Phone:
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Patient Alt Phone:
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Mental Status:
• • •
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General Condition
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Dizziness
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Specify
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Nausea/Vomiting
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Specify
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Fever/Chills
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Specify
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Pain (0 - 10 Scale)
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Specify
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IV Site Problems
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Specify
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Activity - Ambulating
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Specify
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Dressing: Dry & Intact
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Specify
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Drainage
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Specify
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Does the patient understand post-op instructions?
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Were the instructions adequate?
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Is there anything we could have done to make your stay better?
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Patient Comments
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Instructions given to patient:
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Interviewer:
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Date:
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Time:
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First Attempt
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Date
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Time
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Message Left
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Family Member
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Initials
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Second Attempt
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Date
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Time
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Message Left
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Family Member
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Initials
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