BP, pulse and blood loss stable and within normal range	YES	NO	N/A
Blood loss	□	□
Tolerable nausea and no vomiting	□	□
Passing urine normally if relevant	□	□
Taken food and fluids	□	□	□
Mobile without feeling faint	□	□	□
IV cannula removed	□	□	□
Dressing clean and dry (please state types of dressing supplied)	□	□	□
Pressure areas checked	□	□	□
Patient safe on crutches	□	□	□
Post-op instructions and advise sheet given	□	□	□
Medication given and usage explained	□	□	□
Patient aware of re OPA_________/Details to be posted	□	□	□
Medical/Self certificate	□	□	□
Discharge letter: GP □ Practice nurse □ District nurse □	□	□	□
Day surgery only: Escort home and career to stay overnight	□	□	□
Social support (if yes, describe)	□	□	□
Telephone follow-up arranged for morning	□	□	□
Did Doctor see the patient before discharge?	□	□	□
Procedure specific protocol completed	□	□	□