What are the essential components of preoperative (pre-op) clearance documentation for a patient undergoing surgery, considering their medical history, current medications, and comorbid conditions?

Essential Components of Preoperative Clearance Documentation

Preoperative clearance documentation must include a comprehensive risk assessment with specific documentation of active cardiac conditions, functional capacity, surgical risk stratification, and targeted laboratory testing based on patient-specific risk factors—not routine testing for all patients. 1, 2

Core Documentation Requirements

Patient Demographics and Surgical Classification

• Document patient age, planned surgical procedure, and surgical risk classification (low/intermediate/high invasiveness) 3
• Record ASA physical status classification (1-5) based on systemic disease severity 3
• Note timing of assessment relative to surgery date—for high surgical invasiveness or high severity of disease, assessment must occur prior to day of surgery 3

Active Cardiac Conditions Requiring Immediate Attention

Screen for and explicitly document presence or absence of unstable cardiac conditions that mandate evaluation and treatment before proceeding: 4, 2

• Unstable coronary syndromes (unstable or severe angina CCS class III-IV, recent MI within 30 days) 4
• Decompensated heart failure (NYHA class IV, worsening or new-onset HF) 4
• Significant arrhythmias (high-grade AV block, symptomatic ventricular arrhythmias, uncontrolled atrial fibrillation with HR >100 bpm) 4
• Severe valvular disease (severe aortic stenosis with mean gradient >40 mmHg or valve area <1.0 cm², symptomatic mitral stenosis) 4

Cardiovascular Risk Factor Documentation

Document all cardiovascular risk factors as these determine need for further testing: 4

• Documented coronary artery disease 4
• History of heart failure 4
• Cerebrovascular disease (prior stroke, carotid stenosis) 4
• Diabetes mellitus (particularly insulin-dependent) 4
• Renal insufficiency (creatinine >2.0 mg/dL) 4
• Hypertension 4
• Peripheral vascular disease 4
• Obesity 4
• Tobacco use 4

Functional Capacity Assessment

Document exercise tolerance in metabolic equivalents (METs)—this is critical for risk stratification: 4, 2

• Ability to climb ≥2 flights of stairs or walk 4 blocks indicates ≥4 METs and generally permits proceeding without further cardiac testing 4, 2
• Patients classified as high risk but asymptomatic with good functional capacity (e.g., runs 30 minutes daily) may need no further evaluation 4
• Sedentary patients with poor functional capacity require more extensive evaluation 4

Risk-Stratified Laboratory and Diagnostic Testing

Electrocardiography

Order 12-lead ECG selectively, not routinely: 1, 2

• Required for patients with cardiovascular disease or risk factors undergoing intermediate/high-risk surgery 1, 2
• Indicated for patients with recent chest pain or ischemic symptoms 1
• Not needed for asymptomatic patients without risk factors undergoing low-risk surgery 1

Complete Blood Count

Order CBC only when clinically indicated: 1

• Diseases increasing anemia risk (liver disease, hematologic disorders, chronic kidney disease) 1
• History of anemia or recent blood loss 1
• Anticipated significant perioperative blood loss 1
• Cardiovascular surgery and specific high-risk procedures 1

Electrolytes and Renal Function

Reserve for patients at risk of abnormalities: 1

• Chronic kidney disease, hypertension, heart failure, complicated diabetes, or liver disease 1
• Medications predisposing to electrolyte abnormalities (diuretics, ACE inhibitors, ARBs, NSAIDs, digoxin) 1
• All patients undergoing neurosurgery or cardiovascular surgery 1

Coagulation Studies

Order only for specific indications: 1

• Personal or family history of bleeding disorders 1
• Medical conditions predisposing to coagulopathy (liver disease) 1
• Current anticoagulant use 1

Additional Testing Based on Comorbidities

• Random glucose for patients at high risk of undiagnosed diabetes 1
• Hemoglobin A1C for diagnosed diabetics only if results would change perioperative management 1
• Chest radiography only for new or unstable cardiopulmonary symptoms, not routinely 1
• Urinalysis only for urologic procedures or implantation of foreign material 1

Preoperative Optimization Documentation

Medical Condition Optimization

Document optimization efforts for modifiable risk factors: 4, 2

• Smoking cessation implemented at least 4 weeks before surgery 2
• Alcohol abstinence for 4 weeks for patients consuming >2 units daily 2
• Optimization of diabetes, hypertension, and anemia 4, 2
• Correction of anemia and comorbidities 4

Medication Management

Document current medications with specific attention to: 4

• All prescription medications and dosages 4
• Herbal and nutritional supplements 4
• Over-the-counter medications 4
• Alcohol, tobacco, and illicit drug use 4
• Plan for perioperative continuation or modification of medications 4

Patient Education and Shared Decision-Making

Risk Communication

Document discussion of perioperative risks with patient: 4, 2

• Patients in whom prolonged procedures or substantial blood loss is anticipated should be informed of increased POVL risk 4
• Patients with preoperative conditions (male sex, obesity, vascular disease) should be informed these may increase POVL risk 4
• Provide information in multiple formats (oral, written, multimedia) 4, 2

Surgical Details and Expectations

Document counseling provided regarding: 4

• Surgical procedure details 4
• Expected hospital stay and discharge criteria 4
• Stoma education if applicable (independent risk factor for delayed discharge) 4

Common Pitfalls to Avoid

Do not use the phrase "cleared for surgery"—this is inadequate and fails to communicate specific findings and recommendations. 4 Instead, document specific cardiac risk assessment, functional capacity, and any conditions requiring optimization 4

Do not order routine testing for all patients regardless of risk factors—testing should be driven by clinical history, comorbidities, and whether results will change perioperative management 1, 2

Do not delay assessment until day of surgery for high-risk patients or high-invasiveness procedures—these require advance evaluation 3

Do not fail to communicate findings directly with surgeon, anesthesiologist, and patient—clear documentation in the medical record plus direct communication is essential 4

For healthy patients (ASA Class 1) undergoing low-risk/minor surgery, document that no routine preoperative testing is indicated—this evidence-based approach avoids unnecessary testing 1