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PACU Admit Time _____ AM/PM
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Surgeon
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Procedure
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Anesthesia Provider
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Gnl Anes
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MAC
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Airway Patient
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Chin Lift:
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Report From:
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Pt Position
• • •
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Head of Bed - Degrees of Elevation
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ALLERGIES
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NKA
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O2 via ...
• • •
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Drains
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Cap Refill
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OP Site
• • •
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Dressing Change
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Pre-op
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BP
/
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Aldrete
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Admit
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Extremities
|
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Respirations
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BP
|
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Alert/Oriented
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O2
|
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Aldrete Score Total (Please add the values from the last 5 responses)
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|
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Pain 0-10
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Blood Pressure
/
|
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Temp
|
O2 Sat/respirations
|
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Nausea/Vomiting
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Cardiac Monitor On
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SCDs On
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Ice/Polar Care to OP Site
|
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Drain intact and functioning
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|
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q5 (1)
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|
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Extremities
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Respirations
|
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BP
|
Alert/Oriented
|
|
O2
|
Aldrete Score Total (Please add the values from the last 5 responses)
|
|
Pain 0-10
|
Blood Pressure
/
|
|
Temp
|
O2 Sat/respirations
|
|
Nausea/Vomiting
|
Cardiac Monitor On
|
|
SCDs On
|
Ice/Polar Care to OP Site
|
|
Drain intact and functioning
|
|
|
q5 (2)
|
|
|
Extremities
|
Respirations
|
|
BP
|
Alert/Oriented
|
|
O2
|
Aldrete Score Total (Please add the values from the last 5 responses)
|
|
Pain 0-10
|
Blood Pressure
/
|
|
Temp
|
O2 Sat/respirations
|
|
Nausea/Vomiting
|
Cardiac Monitor On
|
|
SCDs On
|
Ice/Polar Care to OP Site
|
|
Drain intact and functioning
|
|
|
q5 (3)
|
|
|
Extremities
|
Respirations
|
|
BP
|
Alert/Oriented
|
|
O2
|
Aldrete Score Total (Please add the values from the last 5 responses)
|
|
Pain 0-10
|
Blood Pressure
/
|
|
Temp
|
O2 Sat/respirations
|
|
Nausea/Vomiting
|
Cardiac Monitor On
|
|
SCDs On
|
Ice/Polar Care to OP Site
|
|
Drain intact and functioning
|
|
|
q5 (4)
|
|
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Extremities
|
Respirations
|
|
BP
|
Alert/Oriented
|
|
O2
|
Aldrete Score Total (Please add the values from the last 5 responses)
|
|
Pain 0-10
|
Blood Pressure
/
|
|
Temp
|
O2 Sat/respirations
|
|
Nausea/Vomiting
|
Cardiac Monitor On
|
|
SCDs On
|
Ice/Polar Care to OP Site
|
|
Drain intact and functioning
|
|
|
q5 (5)
|
|
|
Extremities
|
Respirations
|
|
BP
|
Alert/Oriented
|
|
O2
|
Aldrete Score Total (Please add the values from the last 5 responses)
|
|
Pain 0-10
|
Blood Pressure
/
|
|
Temp
|
O2 Sat/respirations
|
|
Nausea/Vomiting
|
Cardiac Monitor On
|
|
SCDs On
|
Ice/Polar Care to OP Site
|
|
Drain intact and functioning
|
|
|
q15
|
|
|
Extremities
|
Respirations
|
|
BP
|
Alert/Oriented
|
|
O2
|
Aldrete Score Total (Please add the values from the last 5 responses)
|
|
Pain 0-10
|
Blood Pressure
/
|
|
Temp
|
O2 Sat/respirations
|
|
Nausea/Vomiting
|
Cardiac Monitor On
|
|
SCDs On
|
Ice/Polar Care to OP Site
|
|
Drain intact and functioning
|
|
|
q15
|
|
|
Extremities
|
Respirations
|
|
BP
|
Alert/Oriented
|
|
O2
|
Aldrete Score Total (Please add the values from the last 5 responses)
|
|
Pain 0-10
|
Blood Pressure
/
|
|
Temp
|
O2 Sat/respirations
|
|
Nausea/Vomiting
|
Cardiac Monitor On
|
|
SCDs On
|
Ice/Polar Care to OP Site
|
|
Drain intact and functioning
|
|
|
discharge
|
|
|
Extremities
|
Respirations
|
|
BP
|
Alert/Oriented
|
|
O2
|
Aldrete Score Total (Please add the values from the last 5 responses)
|
|
Pain 0-10
|
Blood Pressure
/
|
|
Temp
|
O2 Sat/respirations
|
|
Nausea/Vomiting
|
Cardiac Monitor On
|
|
SCDs On
|
Ice/Polar Care to OP Site
|
|
Drain intact and functioning
|
|
|
Medications
|
|
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Time
|
Drug
|
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Dose
|
Route
|
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RN Initials
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Patient Response
|
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Add medication (1)
|
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Time
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Drug
|
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Dose
|
Route
|
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RN Initials
|
Patient Response
|
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Add medication (2)
|
|
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Time
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Drug
|
|
Dose
|
Route
|
|
RN Initials
|
Patient Response
|
|
Add medication (3)
|
|
|
Time
|
Drug
|
|
Dose
|
Route
|
|
RN Initials
|
Patient Response
|
|
Add medication (4)
|
|
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Time
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Drug
|
|
Dose
|
Route
|
|
RN Initials
|
Patient Response
|
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Fluid Total - In:
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Fluid Total - Out:
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IV Removed - tip intact
|
Initials
|
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Personal Belongings Returned
|
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Discharge Instructions
|
given to ___ who voiced understanding
|
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Patient seen by MD or anes
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at __(time)__ and ready for discharge
|
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Notes:
|
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Patient transported via wheelchair accompanied by
|
Time of discharge
|
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RN Signature
|
Time/Date
|
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Anesthesia Signature
|
Time/Date
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