From the Guidelines
A comprehensive pre-operative note should include the patient's identifying information, diagnosis, planned procedure, informed consent confirmation, NPO status, allergies, current medications, relevant medical history, vital signs, physical examination findings, laboratory results, and any special considerations, as outlined in the most recent guidelines 1. When creating a pre-operative note, it is essential to consider the patient's overall health and any potential risks associated with the surgery. According to the Enhanced Recovery After Surgery (ERAS) society recommendations 1, preoperative education is crucial in establishing clear expectations about the surgical and anesthetic care plan, ensuring that the patient and their families understand their role in successful recovery, and establishing discharge plans preoperatively. Some key elements to include in the pre-operative note are:
- Patient's identifying information
- Diagnosis and planned procedure
- Informed consent confirmation
- NPO status and any dietary restrictions
- Allergies and current medications
- Relevant medical history, including any previous surgeries or medical conditions
- Vital signs and physical examination findings
- Laboratory results, including any relevant blood work or imaging studies
- Any special considerations, such as the need for prophylactic antibiotics or a time-out procedure As recommended by the ERAS society 1, patients should receive preoperative education in oral, written, and/or pictorial format, and optimization of medical conditions, such as smoking cessation and alcohol intake, should be considered 4 weeks before surgery. Additionally, the note should clearly state the surgical site, side (if applicable), and any specific equipment or implants needed, as well as document that a time-out procedure will be performed and that prophylactic antibiotics have been ordered if indicated, as suggested by 1. It is also important to note that routine pre-operative investigations, such as full blood count and urea and electrolyte analyses, are required before surgery, while coagulation studies and chest radiography are required only if clinically indicated, as stated in 1. However, the most recent and highest quality study 1 should be prioritized when making a definitive recommendation. In terms of specific pre-operative care items, the ERAS society recommendations 1 suggest that patients should be screened for smoking, alcohol usage, hypertension, diabetes, and anemia, and have a nutritional assessment, preoperative HIV testing in countries with high HIV/AIDS prevalence, and delirium screening. The use of mechanical bowel preparation, fasting, and carbohydrate drinks should also be considered, as well as the selective use of premedication and the routine use of a surgical safety checklist, as outlined in 1. Overall, a thorough pre-operative note is crucial for patient safety, continuity of care, and medicolegal purposes, and should be based on the most recent and highest quality evidence available 1.
From the FDA Drug Label
To prevent postoperative infection in contaminated or potentially contaminated surgery, recommended doses are: 1 gram IV or IM administered 1/2 hour to 1 hour prior to the start of surgery. The FDA drug label does not answer the question.
From the Research
Preoperative Note Components
A sample preoperative (pre-op) note should include:
- A complete review of systems, especially cardiovascular and pulmonary 2
- Medication history, allergies, surgical and anesthetic history, and functional status 2
- Risk factors for cardiac and pulmonary complications and a determination of the patient's functional capacity 3
- Laboratory investigations should be ordered only when indicated by the patient's medical status, drug therapy, or the nature of the proposed procedure 3
Preoperative Evaluation
The preoperative evaluation should focus on:
- Reducing the patient's surgical and anesthetic perioperative morbidity or mortality 3
- Returning the patient to desirable functioning as quickly as possible 3
- Optimizing the patient's health for the procedure, including proper consultations with appropriate medical services 3
Preoperative Preparation
Preoperative preparation involves:
- Procedures implemented based on the nature of the expected operation and the findings of the diagnostic workup and preoperative evaluation 3
- Preoperative medication, such as benzodiazepines, to reduce stress and internal tension 4
- Administration of premedication at the appropriate time point to ensure optimal effect 4
Importance of Accurate Documentation
Accurate and complete preoperative notes are essential for: