PACU Observation Form
Use this form to record PACU observation details, recovery status, and next-step disposition.
Patient and Procedure Details
Patient Name
*
First Name
Middle Name
Last Name
Observation Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Procedure Type or Procedure Name
*
Recovery Room / PACU Bay or Bed Identifier
*
PACU Observation Status
Current Level of Consciousness
*
Awake
Drowsy
Sleepy
Difficult to Arouse
Pain Level (0-10)
*
No pain
0
1
2
3
4
5
6
7
8
9
Worst pain
10
0 is No pain, 10 is Worst pain
Nausea or Vomiting
*
None
Nausea
Vomiting
Nausea and Vomiting
Respiratory Status
*
Unlabored
Mildly Labored
Requires Supplemental Oxygen
Airway Support Needed
Vital Sign / General Observation Note
Disposition and Follow-up
Readiness for Discharge or Transfer
*
Ready for discharge
Ready for transfer
Extended observation needed
Not ready yet
Destination / Next Step
*
Please Select
Discharge home
Inpatient unit
Extended observation
Transfer to another facility
Other
Nurse / Clinician Initials or Name
*
Submit
Should be Empty: