Intraoperative charting (Narrative) PACU Notes (FDAR)
FOCUS will be the procedure to be done to patient. Example: FOCUS will be the procedure done to patient. Example:”Status-
“Scheduled for laparoscopic cholecystectomy.” post laparoscopic cholecystectomy”
Received patient via ________accompanied by ________, D> Into recovery room with ongoing IVF of _______x____ at
transport aide, and nurse on duty. With an ongoing IVF of _____cc level infusing well at_______. (include any other
_______x____ at _____cc level infusing well pertinent data such as pt. status, dressing, consciousness, ROM,
at_______infusing well at ______. (include any other pain scale, other contraptions, etc.)
pertinent data such as pt. Status and other contraptions) A> Attached to cardiac monitor, determined any untoward signs
Secured consent for procedure and anesthesia signed and symptoms, attached to O2 at_____LPM via _______,
by_________. positioned patient in_______,raised side rails and set bed to
Received ward endorsement. lowest position, regulated IV fluid as ordered…..
Brought to anesthesia treatment room. --------any other interventions done depending on the
Wheeled to OR______ and transferred to OR bed. patient’s status and problems--------
Secured in supine position and attached to cardiac monitor R> Endorsed back to room with ongoing IVF of _______x____ at
with initial vital signs of PR=____, _____cc level infusing well at_______. (include any other
RR=____,BP=______,sPO2=_____ pertinent data such as pt. status, dressing, consciousness, ROM,
Hooked to 02 at _____LPM via________. (if indicated) pain scale, other contraptions, etc.)
Anesthesia induction via ______by Dr. ___________
Positioned patient in ________and secured. (when
positioned aside from supine)
Attached to cautery pad at__________
Skin prep and draping done.
Initial sponges and instrument count done.
Time-out done and offered prayer.
Operation started.
-------------operative technique (varies depending on the
procedure done. Take note of specimen time collection)-------
Final sponges and instrument count complete and verified by
RN ______.
Closure of incision site layer by layer.
Top dressing applied.
Operation ended.
Anesthesia ended.
Post-op care done.
Post-anesthesia care done.
Brought to recovery room.
Endorsed to with ongoing IVF of ______x______at____cc
level infusing well at_______. (Do your assessment. Include
any contraptions, consciousness, ROM, pain scale, etc)
With latest vital signs of PR=____,
RR=____,BP=______,sPO2=_____