Ambulatory Surgery Report Form
Please complete all sections to report details and outcomes of the ambulatory surgery.
Patient Initials
*
Date of Surgery
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Surgical Procedure Performed
*
Surgical Site
*
Please Select
Head/Neck
Upper Extremity
Lower Extremity
Abdomen
Chest
Other
Surgeon Name
*
Type of Anesthesia
*
Please Select
General
Regional
Local
Sedation/Monitored
Other
Procedure Start Time
*
Hour Minutes
AM
PM
AM/PM Option
Procedure End Time
*
Hour Minutes
AM
PM
AM/PM Option
Immediate Postoperative Complications
*
None
Bleeding
Infection
Nausea/Vomiting
Respiratory Issue
Other
Immediate Outcome / Discharge Status
*
Please Select
Discharged Home
Admitted for Observation
Transferred to Another Facility
Other
Submit Report
Should be Empty: