Preoperative note template

Preoperative Note

Planned Procedure & Timing
- Procedure name, laterality, surgeon/service, facility, and planned date.
- Indication for surgery and urgency (elective, urgent).

History Relevant to Perioperative Risk
- Cardiac, pulmonary, bleeding, endocrine (especially diabetes), renal, hepatic, OSA, and prior anesthesia complications.
- Functional capacity / METS estimate as discussed; active cardiac symptoms (chest pain, syncope, DOE).
- Substance use and smoking status.

Medications & Allergies
- Full list with plan for hold/continue (anticoagulants, antiplatelets, ACEi/ARB, SGLT2i, GLP-1, insulin, herbals).
- Allergies and prior reactions (including latex, anesthesia agents).

Exam & Data
- Vital signs, airway/cardiac/pulmonary focused exam as performed.
- ECG, labs, imaging, and specialty clearances reviewed; results summarized.

Risk Assessment & Optimization
- ASA class or equivalent clinical risk framing if used locally.
- Optimization steps completed or still needed (BP control, anemia, infection treatment, smoking cessation counseling).

Assessment & Clearance
- Medical optimization status: cleared / cleared with conditions / not cleared—pending items listed.
- Communication to surgery/anesthesia as documented.

Patient Instructions
- NPO, medication holding, skin prep, arrival time, ride home, and when to call with fever/URI symptoms.
- Shared decisions and patient questions addressed.