|
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
