LA JOLLA SURGERY CENTER 4510 Executive Drive #200A, San Diego, CA 92121, 858-453-7224
RECOVERY ROOM RECORD
Patient Name: _____________________________________ Date: ____________ Allergies/Notes: _________________________________
TIME
B/P
HR
RR
TOTAL INTAKE
Tumescent
IV OR
IV Recovery
PO
Other
TOTAL IN:
O2 sat
Temp
LOC/
Aldrete
score
TOTAL OUTPUT
SAL
EBL
Urine
Drains
Other
TOTAL OUT:
Report from (RN/Anesthesiologist) __________________
NURSING NOTES/MEDICATIONS
DISCHARGE CRITERIA
VS within normal limits
AxOx3
No Respiratory distress
Drainage WNL
Ambulate without difficulty
IV discontinued
to: (PACU RN) ________________________Time: ____________
Discharge to: ____________________ via: ___________________ with: _____________________
Signature of Anesthesiologist/Surgeon (must be signed prior to discharge): _____________________________________________________
LA JOLLA SURGERY CENTER 4510 Executive Drive #200A, San Diego, CA 92121, 858-453-7224
R.N. Name (print): ________________________ Signature: _________________________ Date: _____________ Surgical Log? (check)