Post-Anesthesia Recovery Note (Office/ASC)

Patient: [name, DOB, MRN]

Date of Service:

Location: [Office / ASC] [Phase I / Phase II / Combined]

Procedure(s):

Surgeon/Operating Physician:

Anesthesia Type: [General / MAC / Regional / Local with sedation]

Procedure End Time:            PACU Arrival Time:

Arrival Assessment

(Provide a brief narrative or structured summary of the patient's condition upon arrival. If an element was not assessed, state "not assessed" with rationale. Reference PACU flowsheet for continuous vital sign trends.)

• Airway/Oxygenation: [patency; oxygen device/flow; SpO₂]
• Respiratory Status: [rate, pattern, work of breathing]
• Hemodynamics: [BP; HR]
• Mental Status: [awake / arousable / following commands / other]
• Temperature: [value or "not assessed" with rationale]
• Pain: [score] using [scale]
• Nausea/Vomiting: [present / absent]
• Surgical Site/Dressing: [clean/dry/intact / drainage / device status]
• Handoff Notes: [recovery-relevant intraoperative concerns] (Include difficult airway, significant blood loss, high-risk medications, or state "none reported.")

Recovery Course

[Concise summary of the recovery period] (For stable, uncomplicated recoveries, a brief statement of stability is sufficient. Include significant events with approximate times. Reference PACU flowsheet for detailed vital trends and MAR for medication administration times.)

• Airway/Respiratory Events: [issue] at [time]; [intervention]; [response] (Omit if none.)
• Hemodynamic Events: [deviation] at [time]; [treatment]; [response] (Omit if none.)
• Pain Management: [medications/interventions given]; [response]; final pain score [score] using [scale]
• Nausea/Vomiting Management: [antiemetics given]; [response]; [oral intake tolerance if attempted]
• Regional/Neuraxial Recovery: [motor/sensory status]; [ambulation status] (Include only if applicable.)
• Complications: [time]; [findings]; [interventions]; [response]; [impact on disposition] (Omit or state "No anesthesia-related complications" if none.)

Discharge

Post-Anesthesia Evaluation (Document all required elements.)

• Respiratory Function: [airway patent; RR; SpO₂; supplemental O₂ if any]
• Cardiovascular Function: [HR; BP]
• Mental Status: [alert and oriented / at baseline / other]
• Temperature: [value or "not obtained" with rationale]
• Pain Level: [score] using [scale]; [adequately controlled: yes / no]
• Nausea/Vomiting: [present / absent]; [controlled: yes / no]
• Hydration Status: [euvolemic / mild deficit / other]
• Anesthesia-Related Complications: [none identified / present with details]
• Discharge Scoring: [Modified Aldrete / PADSS]: [score] at [time] (Include only if used.)

Discharge Decision

• Disposition: [discharge to home / transfer to Phase II / admit]
• Ordering Clinician: [name, role]
• Discharge Order Time:            Actual Discharge Time:

Responsible Adult Escort (Required for home discharge.)

• Escort: [name]; [relationship]; [contact number]
• Present at Discharge: [yes / no]
• Instructions Received: [yes]; [method: verbal / written / teach-back]
• Mode of Transport: [wheelchair to private vehicle / walk / other]
• Escort Requirement Exception: [N/A / exempting physician and rationale if applicable]

Instructions

• Written Discharge Instructions: [provided / not provided with reason]
• Prescriptions: [provided / e-prescribed / reconciled]
• Follow-Up Plan: [provider/clinic; timeframe]
• Return Precautions Reviewed: [yes / no]
• Post-Anesthesia Safety Counseling: [completed / not completed] (Driving, alcohol, decision-making restrictions.)
• Understanding Confirmed: [teach-back / patient verbalized / signed acknowledgment]

Attestation

• Recovery Nurse Attestation

  [I have documented the recovery course and patient condition. Discharge per nursing protocol criteria: [met / not met]. Physician accepting discharge responsibility: [name].]

  Name/Credentials:            Role: [RN / LVN]            Time:

  Signature:

• Anesthesia Provider Post-Anesthesia Evaluation Attestation

  [I personally evaluated the patient's recovery from anesthesia and assessed discharge readiness as documented above. Anesthesia-related complications: none identified / as noted above.]

  Name/Credentials:            Role: [Anesthesiologist / CRNA / AA]            Time:

  Signature: