| Preoperative history/procedures |
- Medication allergies or reactions
- Pertinent earlier surgical procedures
- Underlying medical illness
- Chronic medications
- Acute problems (eg, ischemia, acid-base status, dehydration)
- Premedications (eg, antibiotics and time given, beta-adrenergic blockers, antiemetics)
- Preoperative pain control (eg, nerve blocks, adjunct medications, narcotics)
- Preoperative pain assessment (chronic and acute pain scores)
- NPO status
|
| Intraoperative factors |
- Surgical procedure
- Type of anesthetic
- Type and difficulty of airway management
- Relaxant/reversal status
- Time and amount of opioids administered
- Type and amount of intravenous fluids administered
- Estimated blood loss
- Urine output
- Unexpected surgical or anesthetic events
- Intraoperative vital sign ranges
- Intraoperative laboratory findings
- Drugs given (eg, steroids, diuretics, antibiotics, vasoactive medications, antiemetics)
|
| Assessment and report of current status |
- Airway patency
- Ventilatory adequacy
- Level of consciousness
- Level of pain
- Heart rate and heart rhythm
- Endotracheal tube position
- Systemic pressure
- Intravascular volume status
- Function of invasive monitors
- Size and location of intravenous catheters
- Anesthetic equipment (eg, epidural catheters, peripheral nerve catheters)
- Overall impression
|
| Postoperative instructions |
- Expected airway and ventilatory status
- Acceptable vital sign ranges
- Acceptable urine output and blood loss
- Surgical instructions (eg, positioning, wound care)
- Anticipated cardiovascular problems
- Orders for therapeutic interventions
- Diagnostic tests to be secured
- Therapeutic goals and end points before discharge
- Location of responsible physician
|
