All patients will be carefully monitored, as appropriate to
the procedure performed and the orders of the surgeon.
Unless approved by the physician, all patients shall remain
in recovery period until discharge criteria are met and
PROCEDURE: (for Patients Recovered in the Procedure Room/OR)
Patients undergoing simple procedures may require no pre-,
intra-, or post-procedure monitoring.
When, in the judgment of the surgeon, a patient recovering
from local anesthesia requires post-procedure monitoring,
that patient shall be observed per orders; vital signs shall
be taken, at the least, at the completion of the procedure
and at the time of discharge.
Patients having local anesthesia may drive unless such
privilege is denied via written order of the attending
surgeon; patients having any level of anesthesia other than
local will not be allowed to drive.
PROCEDURE: (for Patients Admitted to the Recovery Process)
Patients may be admitted to the 'Recovery Process' whether
the patient is moved to a designated recovery area or
recovered in the procedure room/operating room. Monitoring
requirements for the 'Recovery Process' are identical
regardless of the location where the patient is recovered.
1. The Recovery Room staff person receiving the patient will
discuss patient status and clinical details with the
nurse and/or staff member moving the patient.
The physical assessment at the time of the completion of
the procedure/admission to the Recovery Room will include;
A. Respiratory rate and competency
B. Blood pressure and pulse
C. Condition of dressing
D. Fluid therapy, if any
E. Level of consciousness
F. Level of comfort
2. Staff will report any unusual observations and/or
readings to the Provider Staff member performing the
3. Staff will
A. evaluate patient's level of consciousness and
B. record vital signs upon completion of procedure
and, when applicable, upon admission to 'Recovery',
and at appropriate intervals until the patient
is stable; and
C. document vital signs
4. Staff will assess respiratory status and administer
oxygen upon the order of the Staff member; in an
emergency, oxygen will be administered as necessary.
5. Staff will position patient for comfort, securing safety
straps and other restraints if necessary.
6. Staff will assess status of any wounds or dressings;
drainage, if any, is documented.
7. IV site, if any, will be checked, and IV volumes charted.
8. Patients recovering from general anesthesia shall have at
least 4 sets of vital signs recorded at specified
intervals (usually every 5 minutes) prior to discharge.
9. Patients recovering from monitored anesthesia care shall
have at least 3 sets vital signs recorded at specified
intervals prior to discharge.
10. The patient may be discharged by a member of the Provider
Staff, or by a clinical staff member using standing
11. Unless denied by surgeon's orders, patients shall be
encouraged to take fluids prior to discharge. Nausea and
vomiting will be charted and reported immediately to the
12. Patients shall be encouraged to void prior to discharge.
13. Unless pre-operative condition or the type of surgery
precludes ambulation, patients will be expected to
demonstrate their ability to ambulate in a safe and
steady manner prior to discharge.
14. The person to whom the patient is released must be an
adult with the capacity of making informed judgments
regarding the care of a post-operative patient.
Instructions shall be given to the patient and to the
caregiver prior to discharge; these will include
information on how to cope with after-hours questions and
Discharge instructions provided to each patient contain
the surgeon's name and phone number.
15. Patients undergoing major procedures, patients considered
to be frail or cared for by a frail caregiver, or those
patients who may have encountered problems during any
procedure will be contacted by phone following surgery by
a member of the staff and/or by the staff member
performing the procedure. Such contact will be
documented in the patient chart.
Approved By Governing Board