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Practice Consideration
Postoperative Documentation (Practice Consideration)
Last AANA revision: 2024
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.