Preoperative Assessment Form

What are preoperative assessments?

Preoperative assessment is a systematic medical evaluation conducted before a surgical procedure to ensure patient safety and optimize surgical outcomes. This comprehensive evaluation helps identify potential risk factors that could affect the surgery and recovery process. Several guidelines are issued on standards of this process, such as the 2014 Guideline on Perioperative Cardiovascular Evaluation by the American College of Cardiology (Fleisher et al., 2014).

Surgical complications occur frequently. Thus, a preoperative evaluation is conducted for proper preoperative risk assessment. This commonly includes a detailed history review, physical examination, and necessary laboratory tests tailored to the patient's condition and planned procedure. It establishes the patient's baseline health status, identifies any underlying medical conditions or possible perioperative cardiac risk, and allows for appropriate perioperative care planning. During this evaluation, healthcare providers carefully review the possible history of respiratory and cardiac disease, medication history, and previous surgical experiences.

The timing of this assessment is equally important. While some routine surgeries may only require evaluation a few days before the procedure, complex cases or surgical patients with multiple medical conditions might need assessment several weeks in advance to allow time for optimization.

Who commonly has to undergo such an assessment?

Preoperative assessment is typically required for all patients scheduled for surgical procedures. One of its main goals is to prevent perioperative cardiac complications, along with potential postoperative pulmonary complications.

Patients undergoing major surgery, including abdominal and thoracic surgery or vascular procedures, then require comprehensive assessment due to the higher risk of perioperative complications.

Similarly, patients with pre-existing medical conditions such as coronary artery disease, cardiovascular disease, myocardial infarction, chronic respiratory disease, chronic obstructive pulmonary disease, or diabetes need thorough evaluation regardless of the planned procedure's complexity.

Even seemingly healthy patients undergoing minor procedures may require basic preoperative assessment. While unable to undergo extensive preoperative assessment, emergency surgery patients still require rapid evaluation of their most critical risk factors to ensure safer surgical outcomes.

What can you find on a Preoperative Assessment Form?

A comprehensive Preoperative Assessment Form contains several key components to gather crucial patient information that can increase perioperative risk and postoperative complications. The form typically begins with basic patient demographics and progresses to a detailed medical history, including current medications, allergies, and previous surgical experiences.

The form includes sections for physical examination findings, particularly vital signs, heart and lung assessment, and airway evaluation. Laboratory test results, when indicated, are documented along with their clinical significance. There is also a dedicated space for anesthesia-specific concerns, including previous adverse reactions and difficult airway history.

How does our Preoperative Assessment Form work?

A well-structured Preoperative Assessment Form is a comprehensive tool for evaluating surgical candidates. Here is a step-by-step guide on how to use this form in your clinical practice:

Step 1: Access and download the template

You can access the template from this guide. Click "Use template" to open it within the Carepatron platform, where you can customize this tool according to the information you or your institution needs. You can also click "Download" to get a free fillable PDF copy of this form.

Step 2: Patient demographics and initial information

Begin by documenting basic patient information, including planned surgery details, contact information, and first point of contact for post-operative care. This section establishes the foundation for the assessment and ensures proper patient identification and surgical planning.

Step 3: Medical history and risk assessment

Complete a thorough review of the patient's medical history, including cardiac status, respiratory function, and other systemic conditions. Document current medications, allergies, and previous surgical experiences.

Step 4: Physical examination and diagnostic results

Record vital signs, physical examination findings, and relevant diagnostic test results. This systematic documentation helps identify potential risk factors and establishes baseline health status. The form includes specific sections for cardiovascular, respiratory, and other system assessments, ensuring comprehensive evaluation even for patients undergoing noncardiac surgery.

Step 5: Risk stratification and recommendations

Conclude by determining overall surgical risk (low, intermediate, or high) and documenting specific recommendations for perioperative management. This final section requires practitioner verification and surgical team review, establishing clear communication channels for all involved healthcare providers.

Why is a Preoperative Assessment Form important?

A Preoperative Assessment Form plays a crucial role in surgical care by providing a standardized approach to patient evaluation and risk assessment. Aside from this, it is also significant for the following reasons:

Patient safety and risk mitigation

The form is a comprehensive screening tool identifying potential risk factors before surgery. This structured approach ensures no critical health information is overlooked during the evaluation process.

Communication and continuity of care

A well-documented form facilitates clear communication among healthcare team members. The form creates a reliable reference point for all practitioners involved in the patient's surgical and healing process.

Legal and quality assurance

The form serves as an essential medical-legal document and quality assurance tool. Documentation of the preoperative evaluation and risk assessment provides important protection for both patients and healthcare providers.

Benefits of using this pre-op assessment form

Using a standardized assessment form offers multiple evidence-based advantages in surgical care delivery.

Clinical excellence

Implementing standardized Preoperative Assessment Forms is associated with reducing surgical delays. The systematic approach ensures a comprehensive evaluation of all relevant health factors, leading to better risk stratification and surgical planning.

Efficiency and resource optimization

The standardized format eliminates redundant questioning and ensures efficient information gathering, allowing optimal resource utilization in busy surgical practices.

Enhanced team communication

The clear, organized format ensures that critical information is readily accessible to all team members, from pre-admission through post-operative care.

Quality assurance and risk management

Systematic documentation through standardized forms can help reduce documentation-related medical errors. This structured approach provides clear evidence of appropriate preoperative evaluation and medical decision-making.

Reference

Fleisher, L. A., Fleischmann, K. E., Auerbach, A. D., Barnason, S. A., Beckman, J. A., Bozkurt, B., Davila-Roman, V. G., Gerhard-Herman, M. D., Holly, T. A., Kane, G. C., Marine, J. E., Nelson, M. T., Spencer, C. C., Thompson, A., Ting, H. H., Uretsky, B. F., & Wijeysundera, D. N. (2014). 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery. Circulation, 130(24). https://doi.org/10.1161/cir.0000000000000106