PACU handoff 12:22 · RN Castillo
HR
76
NIBP
128/74
SpO₂
96% RA
Pain
2/10
Disposition
PACU Phase I → Phase II → home. Continuous SpO₂ monitoring 2h given OSA. Entered by me
Pain plan
Ketorolac scheduled · acetaminophen PRN · oxycodone 5 mg breakthrough only. No long-acting opioid given STOP-BANG 5. Entered by me
PONV
Ondansetron given intra-op · prochlorperazine PRN. Entered by me
DVT
SCDs in PACU · ambulate as tolerated. Entered by me
Verbal SBAR given to Castillo: stable maintenance, single-attempt RSI (Mallampati IV), opioid-spare wake given OSA, PCN anaphylaxis history — cefazolin tolerated without reaction. No anesthesia complications.
— Verbal handoff · Acosta → Castillo · 12:22 · transcribed
Aldrete · time of sign 10/10
2
Activity
2
Resp
2
Circ
2
Conscious
2
SpO₂
CMS attestations all 6
Personally performed by anesthesiologist Modifier AA · attending throughout
11:00 – 12:18
Continuous presence verified no absence > 5 min in induction or emergence
12:18
Pre-anesthesia assessment in chart
10:46
Anesthetic plan documented
10:46
All medications & doses captured
11/11 in ledger
Post-anesthesia evaluation prior to release
12:23
Charge capture · ops view 13 units · ASA III · AA
00740 · Anesthesia for upper GI endoscopy (ERCP)5 base + 6 time + 1 ASA + 1 OSA = 13
Modifier AAapplied
Modifier QS · MACN/A · GA
Time11:08 – 12:18 · 70 min
837P submissionready
Sign · Release · Bill
Clean claim · ready to bill
Defects
0
Routes-to-review
0
Total time
1h 18m
Time on AIMS
~3 min
All 6 CMS attestations · charge capture verified · provenance complete
Defect summary · this case none
✓
No items routed to Reconciliation.
Compare with Whitfield (DNR/DNI) → 2 routes-to-review queued.
Source provenance · this case complete chain
From EHR · 14
From monitor · 26
Entered by me · 18
Entered by CRNA · 4
Inferred by AIMS · 3
Needs confirmation · 0
Underlying audit source (OCR/Voice/Scan/Tap) lives in M&M / Audit. Clinician view shows lineage; ops view shows codes.