Required Preoperative Clearance Tests for Surgery
The checked items on this form indicate the required tests: CBC, urinalysis, PT/PTT, and CMP are the mandatory primary clearance tests, with additional cardiology or pulmonary clearance required only if specifically checked and must be submitted 48 hours before surgery.
Primary Clearance Tests (Checked Items Required)
The form clearly indicates which baseline tests are mandatory through checkmarks:
Complete Blood Count (CBC) - Required for procedures with significant hemorrhage risk or when anemia, thrombocytopenia, or infection is suspected 1
Urinalysis (U/A) - Required prior to intervention, with urine culture obtained if infection is suspected based on clinical findings 1
PT/PTT (Coagulation Studies) - Indicated for patients with medical conditions affecting hemostasis, those on anticoagulants, or with history suggesting coagulation disorders 1
Comprehensive Metabolic Panel (CMP) - Should be obtained when reduced renal function is suspected or for intermediate- and high-risk patients 1
Chest X-Ray - Listed but not checked, therefore not routinely required unless clinically indicated 1
EKG - Listed but not checked, therefore not routinely required for all patients 1
Risk-Stratified Approach to Additional Testing
When EKG IS Indicated (Even Though Not Checked on This Form)
Reasonable for: Patients with known coronary disease, peripheral vascular disease, cerebrovascular disease, or structural heart disease undergoing intermediate- or high-risk surgery 1
May be considered for: Asymptomatic patients except for low-risk surgery, or patients over 65 years of age 1
Not indicated for: Asymptomatic patients undergoing low-risk surgery 1
When Chest X-Ray IS Indicated (Even Though Not Checked)
Only indicated if: Pulmonary symptoms present (cough, hemoptysis), abnormal physical examination, or specific clinical concerns 1
Not routinely indicated for asymptomatic patients or low-risk procedures 2, 3
Additional Clearance Requirements (Only If Checked)
The form explicitly states these are required only if checked and must be faxed 48 hours prior:
Cardiology Clearance Required When:
Patient has major clinical predictors: Unstable coronary syndrome, decompensated heart failure, significant arrhythmias, or severe valvular disease 1
Intermediate predictors with poor functional capacity (<4 METs) undergoing intermediate- or high-risk surgery 1
Must include: Office visit note, and any additional testing performed (stress test, echocardiogram, etc.) 1
Pulmonary Clearance Required When:
Symptomatic pulmonary disease requiring optimization before surgery 1
Must include: Office visit note documenting current status and optimization 1
Critical Timing Requirements
All additional clearance documentation must be faxed 48 hours (2 days) prior to surgery - this is non-negotiable per the form requirements and allows adequate time for surgical team review 1.
Common Pitfalls to Avoid
Do not order unchecked tests routinely - The form design indicates selective testing based on clinical need, not blanket screening 1, 2
Coagulation testing is not universal - Only obtain PT/PTT when specifically indicated by anticoagulation use, liver disease, or bleeding history 1
Stage 3 hypertension (≥180/110 mmHg) must be controlled before elective surgery 1
Recent testing may suffice - Patients with coronary evaluation within past 2 years and stable clinical status may not need repeat testing 1
Functional capacity assessment is critical for determining need for additional cardiac testing in intermediate-risk patients 1