What is an example of a proper preoperative assessment for a patient undergoing surgery?

Preoperative Assessment Documentation

A proper preoperative assessment should include a focused medical record review, targeted patient interview addressing specific risk factors, and a physical examination emphasizing airway, cardiovascular, and pulmonary systems, with documentation tailored to the surgical invasiveness and patient comorbidity level. 1

Essential Components of the Written Assessment

Patient Demographics and Surgical Details

• Document patient age, planned procedure, and surgical risk classification (low/intermediate/high invasiveness) 1
• Note ASA physical status classification (1-5) based on systemic disease severity 1
• Record timing of assessment relative to surgery date 1

Medical History Documentation

• Current diagnoses with emphasis on active cardiac conditions (unstable coronary syndromes, decompensated heart failure, significant arrhythmias, severe valvular disease) 1, 2
• Cardiovascular risk factors: documented coronary artery disease, history of heart failure, cerebrovascular disease, diabetes mellitus, renal insufficiency 1, 2
• Pulmonary conditions: obstructive sleep apnea symptoms, chronic obstructive pulmonary disease, restrictive lung disease 1
• Gastrointestinal motility disorders: gastroesophageal reflux disease, dysphagia symptoms that increase aspiration risk 1
• Bleeding history: spontaneous bruising, excessive surgical bleeding, family history of coagulopathy 1
• Current medications including anticoagulants, diuretics, ACE inhibitors, ARBs, NSAIDs, digoxin, beta-blockers 1, 2
• Alternative therapies and supplements 1

Functional Capacity Assessment

• Document exercise tolerance in metabolic equivalents (METs): ability to climb ≥2 flights of stairs indicates ≥4 METs and generally permits proceeding without further cardiac testing 1, 2
• Note any dyspnea on exertion, distinguishing between deconditioning and underlying cardiac disease 1

Physical Examination Findings

• Airway assessment: Mallampati classification, thyromental distance, neck mobility, dentition 1
• Cardiovascular examination: heart sounds (may be distant in obesity), jugular venous distention, peripheral edema 1
• Pulmonary examination: lung auscultation for wheezing, rales, decreased breath sounds 1
• Vital signs: blood pressure, heart rate, respiratory rate, oxygen saturation, temperature 1
• Body mass index and notation of severe obesity if present 1

Laboratory and Diagnostic Testing Results

Document only tests ordered for specific clinical indications, not routine screening 1, 2:

• ECG: Required for patients with cardiovascular disease/risk factors undergoing intermediate/high-risk surgery; not needed for asymptomatic patients undergoing low-risk procedures 1, 2
• CBC: Indicated for diseases increasing anemia risk (liver disease, hematologic disorders), history of anemia, anticipated significant blood loss 1, 2
• Electrolytes/creatinine: For patients on diuretics, ACE inhibitors, ARBs, NSAIDs, digoxin; those with hypertension, heart failure, chronic kidney disease, diabetes, liver disease 1, 2
• Coagulation studies: Only for bleeding history, liver disease, anticoagulant use—not routine screening 1, 2
• Chest radiograph: For new/unstable cardiopulmonary symptoms, not routine 1, 2
• Pregnancy test: Consider for all females of childbearing age 2

Risk Stratification and Surgical Timing

• For high surgical invasiveness or high severity of disease: assessment must occur prior to day of surgery 1
• For low surgical invasiveness and low severity of disease: assessment may occur on or before day of surgery 1
• For intermediate scenarios: clinical judgment based on specific risk factors 1

Fasting Status Verification

• Document patient education regarding fasting requirements (minimum 4 hours for breast milk, 2 hours for clear liquids in appropriate patients) 1
• Verify patient compliance with fasting instructions at time of procedure 1

Consultation Documentation

• If cardiology or other specialty consultation obtained, document specific questions asked and recommendations received beyond "cleared for surgery" 1
• Note whether consultant identified new findings or provided actionable recommendations affecting perioperative management 1

Common Pitfalls to Avoid

• Do not order tests without specific clinical indication—routine testing identifies abnormalities in only 0.8-22% of cases with management changes in only 1.1-4% 2
• Do not document vague clearances like "cleared for surgery" without specific risk assessment and recommendations 1
• Do not rely on arbitrary age cutoffs for testing decisions—base on clinical characteristics 2
• Do not perform routine preoperative testing for cataract surgery in patients in usual state of health 1, 3
• Do not delay assessment until day of surgery for high-risk patients or high-invasiveness procedures 1

Example Documentation Structure

"65-year-old male with coronary artery disease (stent 2 years ago), hypertension, and diabetes presenting for intermediate-risk surgery (inguinal hernia repair). Functional capacity good—climbs 2 flights stairs without symptoms. Current medications: aspirin, metoprolol, lisinopril, metformin. Physical exam: BP 138/82, HR 68, airway Mallampati II, lungs clear, regular heart rhythm, no edema. ECG shows normal sinus rhythm, old inferior Q waves unchanged from prior. Recent creatinine 1.1, HbA1c 7.2%. ASA Class III. Assessment: Acceptable cardiac risk for planned procedure given stable symptoms and adequate functional capacity. Continue beta-blocker perioperatively. Plan general anesthesia." 1, 2