Anesthesia Quality Improvement pacu discharge



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Anesthesia Quality Improvement PACU Discharge


Case Info

 




Anesthesia type

 

Date of Service

 




Provider ID/Provider NPI

 

Patient ID

 




CRNA ID

 

ASA Physical Status

 




Additional provider

 






Yes

No













Patient is awake and able to contribute to assessment

 

 


































Patient Physical Exam:

Yes

No




Pain Score (10-point VAS scale):

 

 

Mental Status at baseline (Y/N)

 

 




on PACU admission

 

 

Vital Signs at baseline (Y/N)

 

 




Highest pain score

 

 

Airway patency at baseline (Y/N)

 

 




Pain score at time of assessment

 

 






















Postoperative Nausea and Vomitting

 

 




Any occurrence of vomiting

 

 






















Did the patient experience an unexpected event during perioperative care?

Yes

No

Unplanned ICU admission

 

 




Adverse drug reaction

 

 

Unplanned hospital admission

 

 




Delayed emergence

 

 

Awareness

 

 




Respiratory arrest

 

 

Epidural hematoma following spinal or epidural anesthesia

 

 




Reintubation

 

 

Peripheral neurologic deficit after regional anesthesia

 

 




Aspiration

 

 

Corneal injury

 

 




Cardiac Arrest

 

 

Hyperglycemia

 

 




Hypotensive episode

 

 

Hypoglycemia

 

 




Transfusion

 

 

Seizure

 

 




Unplanned reoperation

 

 

Vascular injury

 

 




Death

 

 

Pulmonary edema

 

 







 

 

Bradycardia

 

 







 

 

Arrhythmia

 

 







 

 

Anaphylaxis

 

 

 




 

 

If other, please specify:

 

 

 

 









This is a template. Please modify for local conditions.

The definitions for each data element can be found on the AQI website. Not Part of Patient’s chart




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