POST ANESTHESIA CARE AND DISCHARGE RECORD
Patient: ________________________________________ ID#: _____________________________________
ARRIVAL TIME:
AGENTS/DRUGS 0 5 10 15 20 25 30 35 40 45 50 55 60 TOTALS
FLUIDS NS LR mL
OXYGEN L/min %
ECG
SpO2 IV
200
MONITORS ❏ 22G Catheter
❏ AUTO BP R L 180 ❏ 20G Catheter
❏ ECG (Lead II) ❏ ___________
❏ PULSE OXIMETER 160
R ❏ Antecubital
SYMBOLS 140 L ❏ Radial
SBP V ❏ Dorsum hand
V 120 ❏ N/A
DBP
PULSE • 100 AIRWAY
RESP ❍
❏ Nasal Cannula
POSITION 80 ❏ Nasal Mask
❏ RECLINED ❏ Mask
60 ❏ Nasopharyngeal
❏ SUPINE ❏ Oral
40 ❏ LMA
❏ N/A
20
Discharge Criteria
❏ Normal depth/rate of respiration (2) ❏ Limited breathing/airway (1) ❏ Airway support needed (0)
❏ Moves 4 extremities at will (2) ❏ Able to sit, but not stand (1) ❏ Non-ambulatory (0)
❏ Alert and oriented x 3 (2) ❏ Aroused by verbal stimulus (1) ❏ Aroused by physical stimulus (0)
❏ BP +/- 20% preop (2) ❏ BP +/- 21-40% preop (1) ❏ BP > 40% preop (0)
❏ None or mild nausea w/ no vomiting (2) ❏ Transient vomiting or retching (1) ❏ Persistent nausea and vomiting (0)
TOTAL SCORE = _____ [Patient may be discharged if total score is 8 or higher]
Discharge Vital Signs BP ________/________ HR_________
Disposition
Verbal instructions given to ❏ Patient ❏ Escort Written instructions given to ❏ Patient ❏ Escort
Name of individual accompanying patient ___________________________________ Relationship ____________________________
Discharge to ❏ Home ❏ Other: _________________________________________________________
Post-operative appointment ❏ PRN ❏ One week ❏ 10-14 days ❏ ___________________❏ Confirmed by scheduling staff
Person Discharging Patient ________________________________Person Taking Patient to Vehicle__________________________
Dr. Signature _____________________________________
EMERGENCY RECORD
Patient:___________________________________________________ ID#: ____________________________
Doctor: _________________________________ Staff: _____________________________ Date: ____________
START TIME:
AGENTS/DRUGS 0 5 10 15 20 25 30 35 40 45 50 55 60 TOTALS
mg
mg
M mg
LIDOCAINE 2% 1:100K mg
ARTICAINE 4% 1:100K/200K mg
BUPIVACAINE .5% 1:200K mg
MEPIVACAINE 3% mg
PRILOCAINE 4% 1:200K mL
FLUIDS NS LR mL
NITROUS OXIDE L/min
OXYGEN L/min
ECG IV
SpO2
MONITORS ❏ 22G Catheter x___
mmHg
❏ 20G Catheter x___
❏ AUTO BP R L 200
❏ __________ x___
❏ ECG (Lead II)
180 ❏ ___G IO Tibia x___
❏ PULSE OXIMETER
R ❏ Antecubital x___
❏ STETHOSCOPE 160
❏ CAPNOGRAPH L ❏ Radial x___
❏ Dorsum hand x___
❏ AED 140
SYMBOLS 120 AIRWAY
SBP V ❏ Nasal Cannula
V
DBP 100 ❏ Nasal Mask
PULSE • ❏ Mask
80 ❏ LMA
RESP ❍ ❏ Nasopharyngeal
AED ❏ Oral
* 60
❏ King
POSITION ❏ ET Tube
40
❏ RECLINED
❏ SUPINE 20
❏ TRENDELENBERG
0
❏ 911 CALLED AT: _____________________ CALLER:_______________________________________________________________________
HISTORY OF EVENT: __________________________________________________________________________________________________
BRIEF MEDICAL HISTORY: ______________________________________________________________________________________________
MEDICATIONS:____________________________________________________________________ALLERGIES: _________________________
REMARKS/DISPOSITION: _______________________________________________________________________________________________
Dr. SIGNATURE: _________________________________________RECORDER SIGNATURE: ________________________________________
NOTE: COPY FOR EMS
