Post-Anesthesia Evaluation Note

Patient Name: [Patient name] | MRN: [MRN] | DOB: [DOB]

Procedure Date: [Procedure date]

Procedure(s) and Primary Service: [Procedure(s)] — [Primary service]

Anesthesia Type: [general / regional / MAC / combination]

Evaluation Location: [PACU / ICU / floor / other]

Evaluator: [Evaluator name], [Credentials], [Role]

Anesthesia End Time: [Time]

Post-Anesthesia Evaluation Completion Time: [Time]

Brief Recovery Context

• [Airway status at end of case]
• [Immediate respiratory support at evaluation]
• [Key intraoperative issues relevant to recovery]

(Limit to 2–4 concise bullets; detailed intraoperative documentation belongs in the anesthesia record. Only include issues that directly impact recovery assessment.)

Patient Participation

Participation: [Yes / No / Partial]

[If No or Partial: reason and statement that subjective elements assessed using objective surrogates]

(Reason required if No or Partial; omit this line entirely if Yes.)

Recovery Assessment

• Respiratory: [Airway patency; respiratory rate; SpO2 with O2 delivery; work of breathing; stability conclusion]
• Cardiovascular: [BP; HR; rhythm if abnormal; hemodynamic stability; interventions if any; stability conclusion]
• Mental Status: [Level of consciousness; orientation; ability to follow commands; emergence delirium if present; conclusion]
• Temperature: [Measured value; normothermic vs abnormal; shivering and treatment if applicable; conclusion]
• Pain: [Pain score and location; adequacy of control; analgesics given in recovery; regional block effectiveness if applicable; conclusion]
• Nausea/Vomiting: [Presence or absence; antiemetics and response if applicable; conclusion]
• Hydration: [Clinical volume status; IV fluids or oral intake relevant to disposition; conclusion]

(All seven domains required. For any element that cannot be assessed, document "Unable to assess: [reason]" with objective surrogates when possible. Never silently omit a domain.)

Complications

[No apparent anesthetic complications at time of evaluation]

(If complication present, replace the above statement with structured description below:)

• Event: [What occurred and timing]
• Current status: [Resolved / Improving / Ongoing — current patient condition]
• Actions taken: [Interventions, consults, tests initiated]
• Communication: [Patient/family notification; handoff to receiving team]
• Follow-up plan: [Monitoring, re-evaluation timing, outpatient follow-up]

Disposition

Destination: [home / Phase II recovery / floor / stepdown / ICU]

Readiness: [Discharge/transfer criteria met / Not yet met — rationale if not met]

Recovery score: [Aldrete / PADSS / other] = [Score] at [Time]

Anesthesia-specific precautions: [OSA precautions / continuous pulse oximetry / fall risk from regional block / driving restrictions / none]

Handoff: [Verbal report given to receiving team: Yes / No — if Yes, to whom]

(Include recovery score only if scoring system used at facility. Omit handoff line if not applicable.)

Electronic Signature: [Evaluator name], [Credentials]

Signed Date/Time: [Date and time]