Post-Procedure Recovery/Discharge Note (Pain Procedures)

Date: [date]

Procedure(s): [name, laterality, level(s)/site(s)]

Indication: [indication/target symptoms]

Proceduralist: [name/credentials]

Sedation: [none / local only / minimal / moderate / MAC]

Procedure End Time: [HH:MM]

Discharge Time: [HH:MM]

Escort: [name/relationship and transport method] (If transferred or admitted, note destination and receiving clinician instead.)

(This recovery note complements but does not replace the procedure note. Avoid repeating procedural technique; summarize recovery status and disposition.)

Recovery Status

[Brief recovery narrative] (In 2–4 sentences, summarize procedure tolerance; current mental, respiratory, and hemodynamic status; any immediate symptoms and interventions; and discharge readiness.)

Vitals: [last recorded BP, HR, SpO2; note stability] (If detailed time-series vitals exist in a flowsheet, summarize key trends and reference that continuous monitoring is documented elsewhere.)

Mental Status: [level of consciousness; note return to baseline if sedated] (For local anesthesia only with no sedation, a single statement confirming baseline status is sufficient.)

Pain: [score at discharge; note expected vs unexpected symptoms]

Procedure Site: [dressing status; any bleeding/hematoma/swelling]

Medications in Recovery: [analgesics, antiemetics, fluids, or reversal agents given] (State "None required" if applicable.)

Neurologic Check

(Include this section when the procedure could affect neurologic function—e.g., neuraxial/spine procedures, transforaminal injections, RFA near motor/sensory structures, peripheral nerve blocks—or when new neurologic symptoms are reported. Omit for low-risk procedures such as isolated joint injections or trigger points when no neurologic symptoms are present.)

Motor: [relevant muscle groups for procedure site; note symmetry and strength compared to baseline]

Sensation: [relevant dermatomes or peripheral nerve distributions compared to baseline]

Gait: [assessment findings if evaluated]

Bowel/Bladder: [patient-reported status] (Include for neuraxial procedures.)

(If any deficit is present, document onset timing, progression, actions taken, and escalation decision. If effects are expected and transient from local anesthetic, state this explicitly.)

Complications

[Complication status and details] (Always address this section. If none, explicitly state: "No immediate complications observed during recovery." Do not state "no complications" if key assessments were not performed; instead specify what was assessed. If an event occurred, document type, severity, timing, interventions performed, response, and disposition.)

Discharge and Follow-up

Criteria Met: [confirmation that discharge criteria were met: vitals stable, mental status at baseline, pain controlled, procedure site acceptable, written instructions provided, responsible escort present]

Instructions Provided: [confirm patient/caregiver received written instructions and had opportunity to ask questions] (Instructions should address activity guidance, site care, medication resumption timing especially anticoagulants, glucose monitoring if steroid given, and red-flag symptoms: new/progressive weakness or numbness, loss of bowel/bladder control, severe positional headache, fever, signs of infection, severe escalating pain.)

Follow-up: [appointment date/time or scheduling plan]

Expected Response: [tailored expectations based on procedure type: diagnostic block relief window, steroid onset and duration, RFA delayed onset with possible post-ablation neuritis]

Outcome Tracking: [pain diary instructions, percent relief for diagnostic blocks, functional measure, data collection method]

Patient meets discharge criteria and is discharged to [home with escort name] with written instructions and return precautions.