Post-Anaesthesia Care Unit (PACU) Note

Post-Anaesthesia Care Unit (PACU) Note Patient Identification: [Record full patient name, hospital folder number or RSA ID if available, date of birth, and gender] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Procedure Details: [State the procedure performed, date of surgery, and the surgical/procedural team involved] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Anaesthesia Details: [Specify the type of anaesthesia administered (e.g. general, spinal, sedation), duration of anaesthesia, and any blocks or adjuncts used] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Intraoperative Course: [Summarise the intraoperative period including haemodynamic trends, fluid or blood loss, complications, and notable events (e.g. difficult intubation, resuscitation, transfusions)] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Postoperative Assessment: [Describe the patient’s general condition on arrival in PACU – e.g. awake, drowsy, stable, requiring support] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Level of Consciousness: [Comment on alertness, orientation, and sedation score (e.g. RASS, AVPU) if applicable] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Airway and Respiratory Status: [Assess airway patency, respiratory rate, oxygen saturation, need for oxygen or airway adjuncts, and ventilatory support if used] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Cardiovascular Status: [Record heart rate, blood pressure, perfusion, ECG findings if relevant, and any vasopressor or cardiovascular support given] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Pain Assessment: [Document pain score (e.g. 0–10 scale) and describe analgesia administered or continued – including IV, oral, epidural, or nerve block agents] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Nausea and Vomiting: [Note presence or absence of nausea or vomiting and any antiemetics administered] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Temperature: [Record temperature and note if any active warming or cooling interventions were required] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Fluids and Urine Output: [Document volume and type of IV fluids or blood products given in PACU, estimated urine output or catheter status if monitored] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Medications Administered: [List all medications given in recovery including doses, routes, and times – e.g. analgesics, antiemetics, antibiotics, sedatives] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Complications/Adverse Events: [Record any events such as desaturation, hypotension, shivering, agitation, airway obstruction, or other adverse events in PACU] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Plan and Disposition: [Outline post-recovery plan: monitoring level, pain management plan, discharge criteria met, and patient’s destination (e.g. ward, high care, continued recovery overnight)] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Clinician Signature: [Document name of evaluating clinician, designation (e.g. anaesthetist, recovery nurse), and date/time of note completion] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) (Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care. Use only the transcript, contextual notes, or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes, or clinical note, you must not state that the information has not been explicitly mentioned in your output. Leave the relevant placeholder or section blank if it is not explicitly mentioned. Use as many full sentences as needed to capture all the relevant information from the transcript.)