Patient Name______________________

MR Number________________________

DOB______________________________

POST OPERATIVE RECOVERY RECORD

TO BE COMPLETED BY RECOVERY ROOM NURSE:
Date: Recovery Started: Recovery Ended:
Type of Anaesthesia:  General  MAC  PCB  Local  Others: _________________________
Awareness:  Awake  Drowsy  Breath Sounds  Skin Color
Airway:  None  Oral  Nasal  ETT  Urinary Catheter:________________
O2 Therapy:  None  NC  Mask  ________L/min _______%
VITAL SIGNS
Time:
BP
MEAN
PULSE
TEMP
RR
O2
Time:
BP
MEAN
PULSE
TEMP
RR
O2
SOLUTION VOLUME RATE OF INFUSION TIME STARTED TIME FINISHED

TOTAL FLUIDS GIVEN (ml): Blood Loss: Urine: Emesis

RECOVERY ASSESSMENT CRITERIA DISCHARGE CRITERIA FOR D/C HOME
Alertness Scoring System Score O min 15 min 30 min 45 min 1hr DISCHARGE Discharge Criteria Score DISCHARGE
ACTIVITY: Vital Signs
Able to move 4 extremities voluntarily or on command (2) Vital signs 20% of pre-op values (2)
Able to move 2 extremities voluntarily or on command (1) Vital signs 20-50% of pre-op values (1)
Able to move 0 extremities voluntarily or on command (0) Vital signs 50% of pre-op values (0)
RESPIRATION: Ambulation
Able to breathe deeply and cough freely (2) Steady gait and no dizziness (2)
Dyspnea (1) With acquaintance (1)
Apnaeic (0) No dizziness (0)
CIRCULATION: Nausea and Vomiting
BP is 20% of pre-anaesthetic level (2) No or Minimal (2)
BP is 20% - 50% of pre- anaesthetic level (1) Moderate (1)
BP is > 50% of pre- anaesthetic level (0) Severe (0)
CONSCIOUSNESS: Pain
Fully awake (2) No or Minimal (2)
Arousable (1) Moderate (1)
No response (0) Severe (0)
OXYGEN SATURATION: Surgical Bleeding
Able to maintain 92% on room air (2) No or minimal (2)
Needs O2 to maintain >90% (1) Moderate (1)
<90% even with supplement (0) Severe (0)
Score Score
The patient is ready for the discharge from the Recovery Room when
the total score is 9. The total score is 10
Patient scoring of 9 is considered fit for
discharge to home.

Document Reference Number NWGH/MED/F-012/23 Version 1 Issue Date 01-06-2023

Page 1 of 3
 Patient Name______________________

MR Number________________________

DOB______________________________

PAIN SCORE ASSESSMENT

FLACC Behavioral Pain Assessment Scale (Cognitively Impaired Patient)
CATEGORIES SCORING Score
No particular expression or Occasional grimace or frown; withdrawn, Frequent to constant frown, clenched
Face 0 smile
1
disinterested
2
jaw, quivering chin
Legs 0 Normal position or relaxed 1 Uneasy, restless, tense 2 Kicking or legs drawn up
Lying quietly, normal
Activity 0 position, moves easily
1 Squirming, shifting back and forth, tense 2 Arched, rigid, or jerking
Crying steadily, screams or sobs;
Cry 0 No cry (awake or asleep) 1 Moans or whimpers, occasional complaint 2
frequent complaints
Reassured by occasional touching,
Consolability 0 Content, relaxed 1
hugging, or being talked to; distractable
2 Difficult to console or comfort

0 Relaxed and comfortable 1–3 Mild discomfort 4–6 Moderate pain 7–10 Severe discomfort or pain or both Total:_______
FACES-WONG BAKER NUMERICAL RATING SCALE
(above 1-3 years old, Pre Schooler, School Age, Non-Verbal/Precognitive Language Barrier) (School Age, Adolescence/Adult)
0 Code
1
2 0 No Pain
3
4 1-3 Mild
5
6 4-6 Moderate
7
8 7 and > Severe
9
10 10 Worse
PAIN ASSESSMENT Sign/Date/Time: ____________________________________
Pain: ⃞No ⃞ Yes: Location
Type: ⃞ Dull ⃞ Throbbing ⃞ Radiates ⃞ Intermittent ⃞ Constant ⃞ Others
What Alleviates it?
What aggravates it?
How does it affect activities of daily living?
PAIN ASSESSMENT FLOWSHEET
Signature/ Date/ Pain Scale Used and Rating INTERVENTION Patient’s Response Sign/
Area Time FACES NUMERICAL RATI Pain Pain Not Code
FLACC
RATING
Non-Drug Drug
WONG NG Reduced Relieved Relieved
SCALE Activities Others Tablet Inj Others
BAKER

Patient Teaching:
Discharged with:
DISCHARGE TO:
DISCHARGE PREPARATION
 Preprinted self-care instructions provided  Other topics discussed
 Patient/ family verbalizes understanding of instructions  Competent escort available
 Personal belongings  Medication(s)  Prescription(s)  Sent home with equipment
 Home  Other Specify: _________________________________

ANAESTHETIST’S NAME & SIGNATURE: DATE & TIME:

** ANESTHESIOLOGIST APPROVAL FOR DISCHARGE FROM RECOVERY AREA **
NAME OF ASSIGNED NURSE: SIGNATURE/ID: DATE & TIME:

Document Reference Number NWGH/MED/F-012/23 Version 1 Issue Date 01-06-2023

Page 2 of 3
 Patient Name______________________

MR Number________________________

DOB______________________________

Document Reference Number NWGH/MED/F-012/23 Version 1 Issue Date 01-06-2023

Page 3 of 3