A new approach to postanesthesia care unit documentation

Documentation demonstrates that nursing standards of care have been met. To be an effective tool, a record must be complete and concise. A request to develop PACU care plans became the impetus to revise the PACU record. Perioperative information and physical assessments are data required to formulate individualized plans. Development and implementation of a comprehensive record was a positive outcome of a lengthy but interesting and worthwhile project.