Postoperative Evaluation
Within 72 hours of the administration of anesthetic, but after discharge from the Post Anesthesia Care Unit (PACU), a postanesthetic follow-up note should be written, dated and signed, describing any abnormalities or complications related to the anesthesia given. There is a specific labeled space provided on the back of the anesthesia record for the postoperative note.
If any anesthetic complications occur, the attending anesthesiologist should be notified immediately. Postoperative anesthesia notes must be written and placed in the charts of all patients who are in the hospital longer than 24 hours after surgery. Subsequent follow up notes should be written as necessary.
- If the patient is discharged from the PACU to home, the anesthesiologist must write a postoperative note in the progress notes in addition to completing the required information on the back of the Anesthesia and Operative Record and writing an order to discharge the patient to home.
- If a patient goes from the PACU to another patient care setting (e.g., inpatient bed, Emergency Room Observation Unit, etc.) another note is necessary documenting that the patient was sufficiently alert to be discharged. This note can be written by any housestaff or attending.
- If the patient remains in the hospital beyond 24 hours, the postanesthesia note should be written as described above by an anesthesiologist. For additional information, see "Safety Practices."
Discharge Summary: Discharge summaries are not necessary for routine anesthetics. However, discharge summaries are necessary for all patients admitted directly to the service rather than to another primary service with anesthesiology consulting. This would include, for example, admissions for pain control, hyperbarism and special intensive care problems, such as near drowning. The approved discharge summary format can be found at all dictating stations.
