Post-Anesthesia Care Record (PACU Recovery & Discharge)

ANESTHESIA DEPARTMENT • FORMS F-07/F-07 • CBAHI/JCI COMPLIANT

Patient Name:	MRN:	Date:
Procedure:	Age: M F	Wt: kg BMI:
Surgeon:	Anesthesiologist:
Surgery: Start End Anesthesia: Start End Total: min

🏥 1. IMMEDIATE POST-ANESTHESIA NOTE (F-07)

Transfer Information
Arrival: From: OR ICU Other Mode: Bed Stretcher Chair

✓ Handover Checklist

Patient ID Verified
Anesthesia Summary
Procedure Explained

Status Reviewed
Airway/Pain Discussed
Special Orders

Initial Vital Signs on PACU Arrival
HR: bpm BP: mmHg SpO₂: %	RR: /min Temp: °C Pain Score: / 10

Anesthesia Technique
General Anesthesia Regional MAC Sedation

Airway Management
ETT - Size: Depth: cm LMA - Size: Mask Ventilation Only	Status: Extubated in OR Time: Intubated

IV Access & Fluids
IV Lines: # Loc: Total Fluids: mL EBL: mL Urine: mL

Level of Consciousness
Alert/Awake Drowsy Sedated Unresponsive

PACU Admission Orders
O₂:
IV Fluids:
Pain Mgmt:
Special:

💊 3. PACU NURSING ASSESSMENT

System	Assessment Findings
🫁 Respiratory	Airway Patent Breath Sounds Clear Crackles Wheezes Effort: Normal Shallow Labored
❤️ Cardiovascular	Regular Rhythm Peripheral Pulses Palpable Skin Color: Pink Pale Cyanotic Flushed
🧠 Neurological	GCS: / 15 Pupils: Equal Reactive Motor: Moves All 4 Limbs Weak None
🩹 Surgical Site	Dressing Dry & Intact Bleeding (Amt: ) Drains: Patent Output: mL
🤢 GI / GU	Nausea: Yes No Vomiting: Yes No Urine: Voided Catheter (Output: mL)
😣 Pain	Pain Score: / 10 Relief Adequate: Yes No Last Analgesic Given: at

📊 2. PACU MONITORING (Every 15 Minutes)

Parameter	0	15	30	45	60	90	120
HR (bpm)
BP Sys
BP Dia
SpO₂ (%)
RR (/min)
Temp (°C)
Pain (0-10)
Sedation
O₂ L/min

✅ 4. ALDRETE SCORE (Discharge Requires ≥9)

Criteria	Pts	Adm	30min	Disch
1. Activity 2=4 limbs \| 1=2 limbs \| 0=None	0-2
2. Respiration 2=Deep/Cough \| 1=Dyspnea \| 0=Apneic	0-2
3. Circulation (BP) 2=±20% \| 1=±20-50% \| 0=±50%+	0-2
4. Consciousness 2=Awake \| 1=Arousable \| 0=None	0-2
5. SpO₂ 2=>92% RA \| 1=>90% O₂ \| 0=<90%	0-2
TOTAL (Max 10)	10

✅ DISCHARGE: Aldrete Score ≥ 9 Required

🚪 5. DISCHARGE READINESS CHECKLIST

Complete ALL Before Discharge:

Vital Signs Stable
Airway Patent
Aldrete ≥9
Pain ≤3
N/V Controlled

Surgical Site Dry
Urine Output OK
Oriented x3
Moves Extremities
Orders Reviewed

📋 6. DISCHARGE INFORMATION

Discharge To:
Ward: ICU Step-Down Home Other:

PACU Out Time: Total PACU Time: min

Discharge Vital Signs
BP: mmHg HR: bpm RR: /min	SpO₂: % Temp: °C Aldrete: / 10

Discharge Instructions:

⚠️ 7. COMPLICATIONS IN PACU (If Applicable)

Common Complications - Check if occurred:

Hypotension
Hypertension
Desaturation
Resp. Depression

Excessive Pain
PONV
Emergence Delirium
Hypothermia

Bleeding
Urinary Retention
Arrhythmia
Other

Time	Complication / Event	Intervention / Management	Outcome / Resolution

✍️ 8. PROFESSIONAL ATTESTATION & SIGN-OFF

Professional Statement: I certify that this patient was monitored in PACU per institutional standards. All vital signs documented, assessments completed, patient meets discharge criteria, and appropriate handover provided to receiving team.

PACU Nurse
Name:
Time:

Anesthesiologist
Name:
Time:

Receiving Nurse
Name:
Ward:

Form F-07/F-07 | Post-Anesthesia Care Record | Version 1.0 | Page 1 of 1 | Medical Record - Permanent