How to Document Surgical Clearance
Avoid using the phrase "cleared for surgery" and instead document the patient's cardiovascular and pulmonary stability, optimal medical condition, and specific recommendations for perioperative management. 1
Essential Documentation Framework
Cardiac Assessment Components
Document the absence of active cardiac conditions that are absolute contraindications to elective surgery: 1
- Unstable angina - any rest angina or crescendo pattern 1
- Recent myocardial infarction - particularly within 6 weeks (absolute contraindication) or within 6 months (requires cardiology consultation) 2, 1
- Decompensated heart failure - NYHA class and recent symptom changes 1
- Significant arrhythmias - uncontrolled or symptomatic 1
- Severe valvular disease - especially symptomatic stenosis 1
Document functional capacity explicitly: 1
- Ability to climb 2 flights of stairs or perform 4 METs of activity indicates adequate cardiac reserve 1
- Patients with reasonable functional capacity (able to comfortably walk up one flight of stairs) are not at greater than average risk 2
Document cardiac history: 1
- Prior coronary revascularization (CABG or PCI with stent type and timing) 1
- Presence of pacemaker or ICD 1
- Known valvular disease 1
Pulmonary Assessment Components
Document chronic lung disease status: 1, 3
- COPD (odds ratio 1.79 for postoperative complications) 3
- Asthma control 1
- Obstructive sleep apnea 1, 3
- Interstitial lung disease 1
Document objective pulmonary function: 1, 3
- Post-bronchodilator FEV1 values (if available) 1, 3
- Transfer factor/DLCO (if available) 1, 3
- Oxygen saturation at rest on room air 1, 3
- Respiratory rate and pattern 1
Document functional pulmonary status: 1
- Progressive exertional dyspnea 1
- Exercise intolerance 1
- Recent pulmonary infections or exacerbations 1
Additional Risk Factors to Document
Age: Patients ≥65 years have significantly increased pulmonary complication risk 1, 3
Functional status: 1
- Functional dependence or inability to perform activities of daily living 1, 3
- WHO performance status (≥2 indicates need for careful assessment) 1
Nutritional status: 1
- Weight loss >10% of preoperative weight indicates high risk 2, 1
- Body mass index 2, 1
- Serum albumin level 2, 1
Smoking history: Current or former use 1
Recommended Documentation Template
Instead of "cleared for surgery," use language such as: 1
"Patient is in optimal medical condition for the planned surgical procedure with the following considerations:"
Then list:
- Specific cardiovascular stability assessment 1
- Specific pulmonary stability assessment 1
- Risk stratification (average risk, intermediate risk, or high risk) 3
- Specific perioperative recommendations for medication management 1
- Any additional testing completed or recommended 1
- Multidisciplinary discussion if multiple adverse factors present 2, 3
Critical Pitfalls to Avoid
Do not use blanket clearance statements - they fail to communicate specific risks and management needs 1
Do not proceed with elective surgery if: 2, 1
- Myocardial infarction within 6 weeks 2
- Active decompensated heart failure 1
- Unstable angina 1
- Uncontrolled arrhythmias 1
Patients with multiple adverse medical factors require formal multidisciplinary discussion between chest physician, surgeon, and oncologist before proceeding 2, 3
For patients with cardiac murmurs, obtain echocardiogram before surgery 2, 3
For patients with carotid bruits or history of stroke/TIA, obtain carotid Doppler studies and assess with vascular surgeon if stenosis >70% 2