What should be included in a comprehensive pre‑operative surgical note for a [age]-year‑old [male/female] undergoing [procedure] under [general/regional] anesthesia?

Pre-Operative Surgical Note: Essential Components

A comprehensive pre-operative surgical note must document patient identification, focused medical history with risk stratification, targeted physical examination findings, relevant laboratory results, medication reconciliation, anesthetic plan, and surgical safety checklist completion—with timing and depth determined by surgical invasiveness and patient comorbidity. 1

Patient Identification and Verification

• Verify patient identity, correct surgical procedure, correct surgical site, and document informed consent at the beginning of the note 2
• Record patient's preferred name and pronouns, particularly important for transgender and gender-diverse patients to reduce gender dysphoria 1, 3
• Document sex assigned at birth and current gender identity when relevant to surgical planning, obtained through private screening 1

Medical Record Review and Current Diagnoses

• Review previous anesthetic records specifically for airway difficulties, cardiovascular complications, and adverse reactions 1, 2
• List current diagnoses with treatment status and degree of optimization 1
• Document any cardiac rhythm management devices (pacemaker/ICD) including device type, pacemaker dependency, and last interrogation date 2

Focused Medical History

Cardiovascular Assessment

• Document functional capacity in metabolic equivalents (METs)—ability to climb stairs, walk blocks, perform household activities 1, 2
• Record history of hypertension, coronary artery disease, heart failure, arrhythmias, and current control status 1, 2

Pulmonary Assessment

• Screen for obstructive sleep apnea by documenting: witnessed apneas, loud snoring, frequent arousals, morning headaches, daytime somnolence 1, 2
• Record baseline oxygen saturation and consider overnight oximetry or formal sleep study if severe OSA suspected 2
• Document asthma, COPD, or restrictive lung disease with current symptoms and medication use 1, 2

Allergy History

• Obtain thorough allergy history including previous anaphylactic reactions, specific drug allergies with reaction type, and latex allergy screening 1, 2
• Ask specifically about reactions to balloons, condoms, or latex gloves causing itching, rash, or angioedema 1
• Screen high-risk groups: patients with atopy, spina bifida, multiple childhood surgeries, healthcare workers, and those with fruit allergies (banana, chestnut, avocado) 1
• If latex allergy history is positive or equivocal, document that patient requires latex-specific IgE testing or skin prick testing before elective surgery 1

Additional Systems Review

• Document diabetes with current glucose control and HbA1c if available 2
• Record bleeding disorders, anticoagulant use, and history of abnormal bleeding 2
• Note musculoskeletal abnormalities including osteoarthritis, kyphoscoliosis, or fixed flexion deformities affecting positioning 2
• For patients with uterus and ovarian tissue ages 12-55, document pregnancy test offer regardless of contraception use 1

Medication Reconciliation

• List all current medications with doses, reviewing specifically for inappropriate dosing, potential drug interactions, and medications requiring perioperative adjustment 2
• Document polypharmacy (>5 medications) as this increases adverse drug reaction risk, particularly in patients >70 years 1, 2
• Record decision to continue or hold each medication perioperatively, particularly anticoagulants, antihypertensives, and hormone therapy 1, 2
• Note that gender-affirming hormone therapy should generally be continued throughout the perioperative period unless specific contraindications exist 1

Physical Examination Findings

Airway Assessment

• Document Mallampati score, thyromental distance, mouth opening, neck mobility, and presence of dentition 1, 2
• Note if patient has undergone gender-affirming facial/neck procedures (cricothyroid approximation, vocal pitch-raising surgery) as standard emergency front-of-neck airway may not be possible 1
• Record neck circumference, tonsil size, and tongue volume as OSA indicators 1, 2

Cardiovascular and Pulmonary Examination

• Document vital signs including blood pressure, heart rate, oxygen saturation 1
• Record cardiac auscultation findings and presence of murmurs 1
• Document pulmonary auscultation findings 1

Additional Examination Elements

• Note BMI and body habitus (obesity alone is not a contraindication to surgery but requires documentation) 1
• Document presence of chest binders in transgender patients (should be removed before anesthesia with patient consent) 1

Laboratory and Diagnostic Testing

Order tests based on clinical indications, not routinely 1

• CBC for patients with diseases increasing anemia risk, history of anemia, or anticipated significant blood loss 2
• Electrolytes and creatinine for patients with chronic disease or medications predisposing to electrolyte abnormalities 2
• Random glucose for patients at high risk of undiagnosed diabetes 2
• Coagulation studies (PT, aPTT, platelet count) only for patients with bleeding history, coagulopathy conditions, or anticoagulant use 2
• Pregnancy test offered to all patients with uterus and ovarian tissue ages 12-55 1
• Review sleep study results if available for OSA patients 1

Risk Stratification and ASA Classification

• Assign ASA physical status classification (I-VI) 1
• Document surgical invasiveness level (high/medium/low) as this determines timing requirements for assessment 1
• Note that high surgical invasiveness requires assessment prior to day of surgery; low invasiveness may be done day-of 1

Anesthetic Plan

• Document planned anesthetic technique (general, regional, monitored anesthesia care) 1
• For transgender patients on established hormone therapy receiving TIVA, note that current pharmacokinetic models are not validated—processed EEG monitoring must be used 1
• Record airway management plan, particularly if difficult airway anticipated 1
• Document plan for OSA patients including postoperative monitoring location 1

Perioperative Precautions and Special Considerations

Latex Allergy Protocol (if applicable)

• Document that latex allergy must be recorded in case notes and on patient wrist bracelet 1
• Note that surgical team, nursing, and anesthetic support teams must be alerted 1
• Record that operating theatre requires preparation night before with latex-free environment 1
• Document that patient should be scheduled first on list 1

Fasting Instructions

• Document clear fluid intake allowed up to 2 hours before induction 2
• Light meal allowed up to 6 hours before induction 2
• Consider complex carbohydrate drink (400 mL with 50g CHO) 2 hours preoperatively for elective patients 2

Prophylaxis Plans

• Document antibiotic prophylaxis plan (first-generation cephalosporin within 1 hour of incision for most cases) 2
• Record VTE prophylaxis strategy (compression stockings/pneumatic compression plus LMWH or unfractionated heparin) 2
• For high PONV risk patients, document plan for 2-3 antiemetics 2

Inpatient vs Outpatient Determination

Document decision regarding inpatient vs outpatient management based on: 1

• Sleep apnea status and severity 1
• Anatomical and physiologic abnormalities 1
• Coexisting disease status 1
• Nature and invasiveness of surgery 1
• Need for postoperative opioids 1
• Patient age and social support 1
• Adequacy of postdischarge observation 1
• Capabilities of outpatient facility including emergency equipment availability 1

Communication and Team Brief

• Document that specific perioperative considerations (including name, pronouns, latex allergy, OSA status) will be communicated at surgical brief 1, 2
• Note that transgender status should only be shared with patient consent and if deemed important for safety 1
• Record that appropriate equipment has been verified available 1, 2

Consent and Patient Education

• Document that patient received procedure-specific information in written format 1
• Record that patient understands planned procedure, postoperative care, and consents to day surgery if applicable 1
• For day surgery, document that responsible adult will escort patient home and provide support for first 24 hours 1
• Note that patient's domestic circumstances are appropriate for postoperative care 1

Timing Considerations

For high surgical invasiveness procedures: 1

• Initial assessment of medical records, patient interview, and physical examination must be completed prior to day of surgery 1
• This applies regardless of patient disease severity 1

For low surgical invasiveness procedures: 1

• Assessment may be performed on or before day of surgery 1
• Exception: patients with high severity of disease still require prior-to-surgery assessment 1

Common Pitfalls to Avoid

• Do not order routine preoperative tests without clinical indication—one study showed no difference in day surgery outcomes when all routine investigations were omitted 1
• Do not assume gender-affirming procedures are documented in medical records—many aspects may be absent and require direct patient inquiry 1
• Do not use legal names that differ from preferred names during clinical interactions, particularly for transgender patients 1, 3
• Do not delay assessment until day of surgery for high-risk patients or high-invasiveness procedures—this increases cancellation risk 1
• Do not omit occupational history when screening for latex allergy—healthcare workers and industrial workers using protective gear are high-risk 1