Postoperative Form
The postoperative form documents the patient's recovery from anaesthesia in the recovery room (PACU).
Modified Aldrete Score
The Aldrete score assesses readiness for discharge from the recovery room. Score each criterion from 0 to 2:
| Criterion | 0 | 1 | 2 |
|---|---|---|---|
| Activity | No movement | 2 extremities | All extremities |
| Respiration | Apnoeic | Shallow/limited | Deep breath & cough |
| Circulation | BP ±50% of pre-op | BP ±20–49% of pre-op | BP ±20% of pre-op |
| Consciousness | No response | Arousable | Fully awake |
| SpO₂ | <90% with O₂ | >90% with O₂ | >92% on room air |
Total ≥ 9 indicates readiness for discharge from the recovery room.
The total is calculated automatically and displayed with a colour indicator:
- 🟢 ≥ 9 — Ready
- 🟡 7–8 — Monitor
- 🔴 < 7 — Continue recovery
Recovery vitals
- Temperature (°C)
- Pain NRS — Numeric Rating Scale 0–10 (slider)
- PONV — Postoperative nausea and vomiting (Yes/No)
- Time in PACU — minutes spent in the recovery room
Postoperative state at discharge (disposition)
Select where the patient is discharged to:
| Disposition | Colour |
|---|---|
| Ward | Green |
| PACU (extended stay) | Amber |
| ICU | Red |
Add clinical notes for the receiving team in the free text field below.
Handover instructions
For patients going to the ward or PACU, a checklist of standard handover instructions is available. Tick all that apply:
- Pain management plan
- Nausea/vomiting management
- Fluid balance monitoring
- Wound care instructions
- Mobility restrictions
- DVT prophylaxis
- Special monitoring requirements
- Specific drug instructions
- Follow-up plan
These instructions appear in full text on the printed protocol — not abbreviated codes.
Completing the case
Click Complete case to finalise all three forms and generate the protocol. The case status changes to Case finished on the dashboard.
Once a case is marked complete, editing requires reopening it. Always verify all data before completing.