Post Anaesthesia Recovery Score

  (Also check  Criteria for transfer of patients from OT recovery area)
 

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POST ANAESTHESIA RECOVERY SCORE (MODIFIED ALDRETE)

Patient’s name: _______________________________________ UID: ________________________ Age: ____________________ Gender: ____________________ Department: __________________ Type of Anaesthesia: __________________________ Surgery: ___________________________ Date and time of Anaesthesia: _____________________________________________________

SCORING (Date of scoring ______________; Time ________________) Criteria Scores Patient’s score Remark Activity 2 = Able to move all 4 limbs 1 = Able to move any two limbs only 0 = Unable to move any limb Respiration 2 = Able to breathe deeply and cough freely 1 = Dyspnoea or limited breathing 0 = Apnoeic or unable to breathe Circulation 2 = BP +/- 20% of pre-anaesthetic level 1 = BP +/- 20%-49% of pre-anaesthetic level 0 =  BP +/- >50% of pre-anaesthetic level Consciousness 2 = Fully awake 1 = Arousable on calling 0 =  Not responding O2 saturation 2 = Able to maintain SpO2 >92% on room Air 1 = Needs supplementary O2 to maintain SpO2 >90% 0 =  SpO2 <90% despite supplementary O2 Pain 2 = Minimal to no pain, controllable with oral analgesics 1 = Presence of pain despite analgesic Surgical Bleeding 2 = Minimal/Does not require dressing change 1 = Moderate/Up to two dressing changes required 0 =  Severe/More than three dressing changes required Nausea and Vomiting 2 = None to minimal 1 = Moderate  0 =  Severe  Total score of patient

Interpretation of score: Patient with score of 9 or higher can be considered for shifting out of recovery area

Recommendation: ___________________________________________________________ ___________________________________________________________________________ ____________________________________________________________________________

Assessment and scoring done by; Name: _____________________________________  Designation: _______________________ Signature: ___________________________________ Date: _____________________ Time: ___________________

Advance Directive Form for Passive Euthanasia

Also read - Passive Euthanasia in India and Making Advance Medical Directives: Details that hospitals and patients must know

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ADVANCE MEDICAL DIRECTIVE
A. – ACKNOWLEDGEMENT BY PATIENT
I, __________________________________________ (name of patient giving directive), would like to make and communicate following wishes to those who will be responsible for my healthcare, who must follow the directions written on this form. I acknowledge that, ·         I am major by age and in a sound mind to issue these directives. ·         I can withdraw or modify these directives, in written, at any point of time henceforth ·         I have been explained and I fully understand the consequences of this advance directive
B. EXPLANATION OF TERMS
If I become terminally ill, I want that the life sustaining treatment must be _______________________________________ (continued / not continued) on me If I become terminally ill, I want that food and water provided through a tube or an IV should be ___________________________________________ (continued / not continued) If I become permanently un-conscious, I want that the life sustaining treatment must be _______________________________________ (continued / not continued) on me If I become permanently un-conscious, I want that food and water provided through a tube or an IV should be ___________________________________________ (continued / not continued) I know that even if I choose not to have life sustaining treatment, I will still get medicines and treatments that ease my pain and keep me comfortable I understand that if I am terminally ill or injured I may need to be given food and water through a tube or an IV to keep me alive if I can no longer chew or swallow on my own or with someone helping me Any other directive: _______________________________________________________________ ________________________________________________________________________________
C. EXPLANATION OF TERMS
·                               Terminally ill – is when a qualified doctor or a team of doctor decide that I have a condition that cannot be cured and that I will likely die in the near future from this condition ·                               Life sustaining treatment – Life sustaining treatment includes drugs, machines, or medical procedures (including Cardio-pulmonary resuscitation) that would keep me alive but would not cure me. ·                               Permanent unconsciousness is when a qualified or a team of doctors agree that within a reasonable degree of medical certainty I can no longer think, feel anything, knowingly move, or be aware of being alive. They believe this condition will last indefinitely without hope for improvement and have watched me long enough to make that decision
D. PERSON AUTHORIZED TO GIVE CONSENT ON MY BEHALF
I nominate following person whose consent should be taken before executing the above directives. The person can also make healthcare decisions, not specified here, on my behalf. I ascertain that these persons are of major age and in a decision making state First Choice Name: ____________________________________ Relationship with me: ______________________________ Address: _______________________________________ Second Choice (In case first choice person not available) Name: ____________________________________ Relationship with me: ______________________________ Address: _______________________________________
Instructions (if any) for the person consenting/making decision on patient’s behalf _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________
E. Signatures
Name and signature of the person giving advance directive		Date / Time
Signature of person authorized for consent/decisions: I am willing to make decisions/consent on healthcare related matter on patient’s behalf
Name, signature and relationship of the person (First choice)		Date / Time
Name, signature and relationship (Second choice)		Date / Time
Signature of Witnesses: “I am satisfied that the document has been executed voluntarily and without any coercion or inducement or compulsion and with full understanding of all the relevant information and consequences”
Name and signature of Witness number 1		Date / Time
Name and signature of Witness number 2
Signature of Judicial Magistrate of First Class: “I am satisfied that the document has been executed voluntarily and without any coercion or inducement or compulsion and with full understanding of all the relevant information and consequences”
Name, signature and District of JMFC (With official stamp)		Date / Time

Code Blue Form

Code Blue Form

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Use this form along with 'Code Blue System' 

Type of event           Actual Event            Mock Drill       Date ___________

Patient Details: Name: __________________________________ UID ______________________ Age ____________ Gender ________ Ward / Unit _________________________ Diagnosis (Pre-arrest) ________________________________________________ Any Pre-arrest intervention  ____________________________________________

Code Activation: Code activated by _____________________________ Designation__________ Time of code activation ______________ Condition at the time of code activation: Unresponsive Apnoea No Pulse Gasping Other __________________________________________________________ Time of code team arrival: 1st member __________ 2nd member ____________ Name of code blue team leader_______________ arrival time ______________

Resuscitation measures Duration for which CPR given __________________ Intubation given? Yes/No,        If Yes, then time _______ Central line given? Yes/No,      If Yes, then time _______ Defibrillator used? Yes/No,       If Yes, then time and duration ___________ List of medicine administered: S.No. Medication Dose Remark Other measures:

Outcome Outcome of resuscitation:       Patient survived       Patient Expired Time at which resuscitation efforts stopped: Vitals at stopping:   HR____  BP _______ SPO2 ______Rhythm ________ Patient shifted ICU: Yes/No      If not, location of patient ________________ Post resuscitation advice:  ______________________________________ _______________________________________________________________

Code blue team members and signatures S.No. Members name Signature

Documented by Name:                                                        Date:                          Time: Signature: