Handover Tool: OR to PACU/ICU Transfer (SBAR Format)

ANESTHESIA DEPARTMENT • FORM F-09 • CBAHI/JCI COMPLIANT

Patient Name:	MRN:	Date:
Procedure:	Age: M F	Wt: kg BMI:
Surgeon:	Anesthesiologist:
Transfer: From OR Other To PACU ICU Other Time: Sending: Receiving:

📢 1. SITUATION

Clinical Context

Chief Complaint/Indication:
Procedure Performed:
Procedure Type:	Elective Urgent Emergency
ASA Classification:	I II III IV V VI

Current Patient Status

Clinical Status:

✓ STABLE ⚠ UNSTABLE 🚨 CRITICAL

Code Status: Full Code DNR DNAR Limited (Specify: )

Baseline Vitals: BP: HR: SpO₂: % RR:

⚠️ CRITICAL INFORMATION / RED FLAGS

Immediate Concerns:

None - Routine Transfer Yes - See details below ↓

Difficult Airway
Hemodynamic Instability
Significant Bleeding (mL)
Active Arrhythmias
Respiratory Issues

Neurological Changes
Metabolic Abnormalities
Hypothermia (<36°C)
Coagulopathy
Surgical Complications

Details / Actions Required:

Key Perioperative Events

Intraop Hypotension Hypertension Brady/Tachycardia

Difficult Intubation Desaturation Bronchospasm

Massive Transfusion Vasopressor Inotrope

Notes:

📋 2. BACKGROUND

Medical History

Past Medical Hx:

🚨 ALLERGIES:
Current Medications:

Surgical & Anesthesia History

Previous Surgeries:
Previous Anesthesia Issues:	None Difficult Airway PONV MH Other:

Anesthesia Details (Intraoperative)
Anesthesia Type:	GA Regional MAC Sedation Combined
Timeline:	Induction: Duration: min Total: min
Airway Management:	ETT - Size: Depth: cm LMA - Size: Mask Only Status: Extubated (Time: ) Intubated
IV Access:	# Lines: Loc: Peripheral Central Arterial Other:
Fluid Balance:	Total Fluids: mL EBL: mL UOP: mL Blood Products:
Key Medications Administered:

📊 3. ASSESSMENT

Current Vital Signs - PROMINENT

HR: bpm
BP: mmHg
SpO₂: % on L/min O₂

RR: /min
Temp: °C
GCS: / 15

Pain Score: /10 At Rest On Movement
LOC: Alert Drowsy Sedated Unresponsive
Neuromuscular: TOF: Sensory: Motor:

🏥 BODY SYSTEM	📋 CLINICAL ASSESSMENT
🫁 Respiratory	Airway: Patent Compromised Breath: Clear Crackles Wheezes Diminished O₂: L/min SpO₂>95%
❤️ Cardiovascular	Rhythm: Regular Irregular BP: Within 20% baseline Labile Requires support Perfusion: Good Poor Bleeding: None Minimal Mod Severe
🧠 Neurological	GCS: /15 (E: V: M:) Pupils: PERRLA Unequal Non-reactive Motor: Moves all 4 Weakness Sedation: Appropriate Deep Agitated
🩹 Surgical Site	Dressing: Clean/Dry/Intact Soiled Blood-stained Drains: Type: Output:mL Color: Bleeding: None Yes
🔬 Recent Labs	Hgb: g/dL Glu: mg/dL K⁺: mmol/L ABG: pH: pCO₂: pO₂: Imaging:

🎯 4. RECOMMENDATIONS

⚠️ Immediate Actions & Orders

Monitoring:	Continuous VS Hourly Neuro Invasive I/O Glu Q___hr Other:
O₂ Therapy:	Device: Flow: L/min Target SpO₂: %
Pain Mgmt:	Route: Freq: PRN if Pain > /10
IV Fluids:	Type: Rate: mL/hr Bolus: mL
Meds:

⚠️ Anticipated Issues & Complications

Bleeding Airway Compromise
Hemodynamic Instability
Inadequate Pain PONV
Hypothermia

Emergence Delirium Arrhythmias
Resp. Depression Urinary Retention
Other:

Specific Concerns:
Special Precautions:

📋 Follow-up Orders

Lab Work:	When:
Imaging:	When:
Consults:
Notify MD If: • BP < or > • HR < or > • SpO₂ < % • Pain > /10 • Bleeding > mL/hr • Temp < or > • Other:

✓ HANDOVER VERIFICATION CHECKLIST

Patient Identity Verified
Allergies Communicated
Code Status Confirmed
Anesthesia Summary Given
Procedure Explained
Current Status Reviewed

Airway Status Reviewed
IV Access Verified
Drains/Lines Reviewed
Pain Management Discussed
Monitoring Requirements Clear
Questions Answered

✍️ PROFESSIONAL SIGN-OFF

Sending Anesthesiologist
Name:
Lic#: Time:

Sending OR Nurse
Name:
Date: Time:

Receiving PACU/ICU Nurse
Name:
Unit: Time:

Form F-09 | Handover Tool: OR to PACU/ICU (SBAR) | Version 2.0 | Page 1 of 2 | Medical Record - Permanent