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Practice Consideration
Postoperative Documentation (Practice Consideration)
Last AANA revision: 2024
Our paraphrased summary. The text below is our own condensed phrasing for board review, derived from the AANA Practice Manual document of the same name. The AANA document is the authoritative source — read it on aana.com for legally-binding language.
Postoperative anesthesia documentation completes the medical-legal record + supports quality improvement. Required elements: anesthetic course summary, PACU assessment, pain control plan, discharge criteria, follow-up plan, postop complications.
Key points
- 1.Postop assessment within 24h documented (PACU note, follow-up phone call, or in-person visit)
- 2.PADSS or Aldrete score documented at discharge from PACU
- 3.Adverse events documented with timeline + interventions + outcome
- 4.Closed-loop: any abnormal findings communicated to surgical team + documented
- 5.PONV, pain, urinary retention, respiratory complications all tracked for QI
This is an exam-prep summary, not a substitute for the full AANA document. Read the source at aana.com for authoritative wording. Education only.