UAB Nurse Anesthesia Program
School of Health Related Professions
Patient Post-Anesthetic Evaluation Form
Name of Nurse Anesthesia Resident :
Date of Post-Anesthetic Visit:
Month I Year :
Eval Form # 1
Postoperative Day Patient Visited: 1 2 3 4 5
2
3
4
5
(Circle one)
Date and Type of Surgical Procedure Performed:
Age:
Sex:
Height:
Weight:
ASA PS:
Allergies:
Medications:
Anesthetic Drugs Used
Nonanesthetic Drugs Used by Anesthesia Provider
(eg, labetalol)
Lab Drawn Intraop or in PACU (include results)
Labsdrawn: Yes
No
Overall Assessment of Vital Signs Postop
Stable:
Yes
No
Evidence of Recall:
Abnormal (list values -date & time)
Nausea postop :
Yes
No
Emesis postop :
Yes
No
Yes
No
If present -comment :
Overall Assessment of Postoperative Visit
Uneventful anesthetic without complications (with exception of
possible NN) :
Yes
No
Other- please elaborate (eg, airway problems, hemodynamic
instability) :
The above form is to be used by resident nurse anesthetist (RNA) to provide documentation of having done post-anesthetic visits
on 5 patients they have anesthetized each month. RNA are to submit their forms (all five at one time and stapled together) as part
of the monthly package of forms (see monthly checklist). Completion of these forms is not optional, and must be turned in by the
15th of the following month (eg, April forms should be received no later than May 15). Please continue to make post- anesthetic
rounds whenever possible on each anesthetic you administer. Failure to submit these forms will lead to suspension of clinical
privileges. If handwritten, you must print.
08/16/01