To be completed by the PACU RN receiving report
PATIENT MRN:
Report with Checklist? YES /NO
KEY ELEMENTS
Please circle yes or no if the information listed was given in the
handoff:
1. Patient identified: YES / NO
2. Patient allergy information given: YES / NO
3. Antibiotic information given: YES / NO
4. Intake and output: YES / NO
5. EBL information: YES / NO
6. Pain management discussed: YES / NO
HANDOFF QUESTIONS
1. Did you need to clarify information or call back the provider
after the anesthesia provider completed the handoff?
YES / NO
2. Was the handoff adequate: YES / NO
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