Post-Operative Assessment Form

The Post-Operative Assessment Form provides a standardized framework for monitoring patient recovery immediately following surgery and throughout the post-operative period. It captures critical indicators such as pain levels on a 0-10 numeric scale, wound and incision site status, vital sign trends, and mobility milestones that directly inform clinical decision-making. By documenting these metrics at regular intervals, care teams can quickly identify complications like infection, hemorrhage, or adverse reactions to anesthesia before they escalate.

This template includes targeted assessments for common post-surgical concerns including nausea and vomiting management, fluid intake tolerance, medication compliance, and drain or catheter status monitoring. The structured checklist format ensures that nursing staff and surgical residents capture every required data point during post-operative rounds, reducing variability in documentation quality across shifts and providers.

Ideal for post-anesthesia care units (PACUs), surgical recovery wards, ambulatory surgery centers, and outpatient follow-up clinics, this form supports evidence-based discharge planning by consolidating all recovery benchmarks into a single document. The discharge readiness checklist helps providers confirm that patients meet established criteria before leaving the facility, improving patient safety outcomes and reducing readmission rates.