Pre-Surgical Evaluation Template

Preoperative Assessment:  
Anaesthetic Assessor: Dr. Emily Carter  
Anaesthetic Assessor: Anaesthetist  
Patient Information:  
Patient Medical Record Number: 123456  
Mr: John Doe  
Patient Date of Birth: 1975-06-15  
Age: 48  
Patient Gender: Male  
Surgery:  
State Surgery: Total Knee Replacement  
Reason for Surgery:  
The patient is suffering from severe osteoarthritis in the right knee, leading to significant pain and mobility challenges.  
Medical History:  
Past Medical History: Hypertension, Type 2 Diabetes, Asthma  
Heart disease including pacemaker: No  
Myocardial Infarction: No  
Hypertension: Yes  
Angina: No  
Stroke: No  
Diabetes: Yes, Type 2, managed with Metformin  
Epilepsy: No  
Jaundice: No  
GORD/ Hiatus hernia: No  
Kidney Disease: No  
Arthritis: Yes  
Asthma: Yes  
Chronic respiratory disease: No  
Thyroid disease: No  
Sickle cell status: Negative  
Pregnancy status: N/A  
Current Medications: Metformin, Lisinopril, Albuterol inhaler  
Allergies: Penicillin  
Disabilities or communication needs: None  
Problems with previous anaesthetics: None  
Social History:  
Social History: Non-smoker, occasional alcohol use, retired teacher  
Baseline observations:  
Pulse: 78 beats per minute, regular  
Temperature: 36.7°C  
Conscious level: Alert  
Blood Pressure: 130/85 mmHg  
ECG: Normal sinus rhythm  
Respiratory rate: 16 breaths per minute  
Oxygen saturations: 98% on air  
Weight: 85 kg  
Height: 1.75 m  
BMI: 27.8 kg/m2  
MRSA status: Needs screening  
National Early Warning Score (NEWS2) Assessment:  
Respiration Rate (RR): [ ] 0 - 12-20  
Scale 1: Oxygen Saturation (SpO2): [ ] 0 - ≥ 96%  
Scale 2: Oxygen Saturation (Sp02): [ ] 0 - 88% - 92% or ≥ 93% on air  
Any Supplemental Oxygen: [ ] 0 - No Air  
Temperature (°C): [ ] 0 - 36.1-38.0  
Systolic Blood Pressure (SBP): [ ] 0 - 111-219  
Heart Rate (HR): [ ] 0 - 51-90  
Level of Consciousness (AVPU): [ ] 0 - A (Alert)  
Total NEWS Score: 0  
Summary: Patient has a respiratory rate of 16, oxygen saturation of 98%, and a heart rate of 78, receiving a total NEWS score of 0.  
Family History:  
Family History: Father had hypertension  
Review of Systems:  
Review of Systems: No abnormalities noted in cardiovascular, respiratory, or gastrointestinal systems. No risk of obstructive sleep apnoea.  
Patient ASA status: II  
Mallampati score: II  
Condition of teeth: No false teeth, no loose caps, crowns, or teeth  
Laboratory and Diagnostic Tests:  
Blood Test Results: Normal  
Date: 2023-10-01  
Technique explained and Agreed:  
General Anaesthetic including type: General Anaesthetic planned  
Admission and Plan:  
Plan for surgery: Scheduled for 2023-10-15 at 8:00 AM, patient to arrive at 6:00 AM. Preoperative instructions include fasting from midnight and stopping aspirin 5 days prior.  
DVT Prophylaxis: TEDS  
Consent:  
Informed consent has been obtained from the patient.  
Other Information:  
Infection risks: None  
Multiple consultant cases: No  
Specialist equipment required: None