Anesthesia Quality Improvement PACU Discharge
Case Info
Anesthesia type
Date of Service
Provider ID/Provider NPI
Patient ID
CRNA ID
ASA Physical Status
Additional provider
Yes No
Patient is awake and able to contribute to
assessment
Patient Physical Exam:
Yes No
Pain Score (10-point VAS scale):
Mental Status at baseline (Y/N)
on PACU admission
Vital Signs at baseline (Y/N)
Highest pain score
Airway patency at baseline (Y/N)
Pain score at time of assessment
Postoperative Nausea and Vomitting
Any occurrence of vomiting
Did the patient experience an unexpected event during perioperative care?
Yes No
Unplanned ICU admission
Adverse drug reaction
Unplanned hospital admission
Delayed emergence
Awareness
Epidural hematoma following spinal or
epidural anesthesia
Peripheral neurologic deficit after regional
anesthesia
Corneal injury
Respiratory arrest
Hyperglycemia
Hypotensive episode
Hypoglycemia
Transfusion
Seizure
Unplanned reoperation
Vascular injury
Death
Reintubation
Aspiration
Cardiac Arrest
Pulmonary edema
Bradycardia
Arrhythmia
Anaphylaxis
If other, please specify:
This is a template. Please modify for local conditions.
The definitions for each data element can be found on the AQI website.
Not Part of Patient’s chart