PACU Transfer of Care/Handoff Note (Anesthesia)

PACU Transfer of Care / Handoff Note

(This template is a concise transition-of-care summary and does not duplicate the full anesthesia record. For safety-critical items that are unknown or not recorded, document "Not documented" or "Unknown" rather than leaving blank.)

Handoff Header

Date/Time of Handoff: [Date and time]
Patient Name: [Patient full name]
MRN: [Medical record number]
DOB: [Date of birth]
Procedure: [Procedure name, including laterality if relevant]
Surgeon: [Surgeon name]
Anesthesia Type: [GA / TIVA / MAC / neuraxial / regional / combined]
ASA Status: [ASA classification]
Transfer Location: [OR → PACU Phase I / OR → ICU / OR → Floor / other]
Allergies: [Allergen(s) and reaction type(s) / NKDA]

Case Summary: [One-line summary of patient, procedure, anesthesia approach, airway status, and stability]

Pertinent Background

(Include only information that changes immediate postoperative risk or management. If none, state "No additional pertinent baseline issues.")

• Airway risk history: [Difficult airway features / OSA / aspiration risk / none relevant]
• Key comorbidities impacting recovery: [Cardiac, pulmonary, renal, or other conditions relevant to immediate care]
• Baseline BP range: [Values / not pertinent]
• Medication considerations: [Chronic opioids or buprenorphine, anticoagulants with neuraxial implications, held beta-blockers, other time-sensitive medications]

Anesthetic Course

(Brief narrative synthesis; do not reproduce the full anesthesia record.)

• Airway management: [Device used, ease/difficulty, view/attempts if relevant, adjuncts used]
• Hemodynamics: [Stable throughout / notable events with interventions, vasopressor/inotrope use and response]
• Neuromuscular blockade: [Agent(s) / none]; Reversal: [Drug, dose, and time / none]
• Fluids: [Type and total volume / not documented]
• Estimated blood loss: [Volume in mL / not documented]
• Urine output: [Volume in mL / not documented]
• Blood products: [Type and units / none]
• Intraoperative complications or notable events: [Description / none]

Airway and Respiratory Status

(Critical section—clearly document current airway and oxygenation status.)

• Current airway status: [extubated / intubated / supraglottic airway in place / tracheostomy]
• Oxygen delivery: [Room air / NC at L/min / face mask at L/min / NRB / HFNC at flow and FiO₂ / other]
• Most recent SpO₂: [Value] on [arrival / time]

(If patient remains intubated, include the following:)

• ETT size and depth: [Size and depth at teeth/gums]
• Ventilator mode/settings: [Mode, FiO₂, PEEP, rate, tidal volume]
• Sedation infusions: [Drug(s) and rate(s), sedation target if applicable]

(If difficult airway or ongoing airway risk, include:)

• Airway concerns and contingency plan: [Specifics and recommended monitoring or interventions]

Lines and Access

(Inventory all active vascular access and devices. If only peripheral IV access, state "PIV only; no invasive lines.")

• Peripheral IVs: [Number and locations]
• Arterial line: [Site / none]
• Central line: [Site and type / none]
• Epidural catheter: [Level and infusion settings / none]
• Peripheral nerve catheter: [Block type, laterality, and infusion settings / none]
• Foley catheter: [present / none]
• Surgical drains/tubes: [Type and location / none]
• Limb restrictions: [Restriction and reason / none]

Analgesia and Antiemetics

(Document medications given intraoperatively and immediately pre-transfer.)

• Opioids: [Drug(s), total dose(s), and time of last dose / none given / not documented]
• Non-opioid analgesics: [Drug(s), dose(s), and time(s) given / none]
• Antiemetics: [Drug(s) and dose(s) / none]

(If regional or neuraxial analgesia was performed, include:)

• Regional/neuraxial analgesia: [Block type, laterality, local anesthetic and concentration, catheter status, infusion settings if applicable, expected sensory/motor effects, fall precautions]

Status at Transfer

• Level of consciousness: [awake / arousable / sedated / unresponsive]
• Pain: [Pain score and scale, or patient report]
• Nausea/vomiting: [none / nausea / vomiting]
• Vital signs on arrival: BP [value], HR [value], RR [value], SpO₂ [value], Temp [value]
• Surgical site/bleeding concerns: [Description / none]
• Temperature management: [Normothermic / hypothermic with active warming / not required]

Recommendations and Action Items

(List active issues requiring monitoring or intervention with specific guidance and thresholds. Include pending tasks and follow-up needs. If none, state "No anesthesia-specific concerns at handoff.")

[Active issues, monitoring recommendations with thresholds and escalation triggers, pending labs/imaging, medication timing, catheter/device follow-up plans, and who to contact for concerns]

Handoff Attestation

• Receiving clinician: [Name and role]
• Method: [in-person / phone / other] (If not face-to-face, document reason.)
• Verbal report given: [Yes]; opportunity for questions provided; questions [asked and answered / none]; receiver acknowledged understanding [Yes]

Author: [Name, credentials, role]