Post-Anesthesia Discharge Form
Complete this form to confirm safe discharge after anesthesia. Ensure all sections are filled for proper patient care and safety.
Patient Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Procedure Performed
*
Type of Anesthesia Used
*
Please Select
General Anesthesia
Regional Anesthesia
Local Anesthesia
Sedation
Other
Current Patient Condition (alertness, orientation, pain, nausea)
*
Vital Safety Checks Completed
*
Stable vital signs
Able to ambulate (if applicable)
Tolerated fluids
Pain controlled
Other
Discharge Readiness Confirmed By
*
Physician
Nurse
Anesthesia Provider
Post-Discharge Escort/Transport Arranged
*
Family member/friend
Medical transport
Other
Home Care and Medication Instructions Provided
*
Wound care
Medication schedule
Dietary instructions
Activity restrictions
Other
Warning Signs Reviewed and Acknowledged
*
Difficulty breathing
Uncontrolled pain
Excessive bleeding
Fever or chills
Other
Acknowledgement of Understanding and Receipt of Instructions
*
Submit Discharge Form
Submit Discharge Form
Should be Empty: