Pre-Operative Assessment Form

The Pre-Operative Assessment Form is an essential clinical tool used to systematically evaluate a patient's fitness for surgery before they enter the operating room. It captures a complete medical history review, current medication inventory, allergy verification, and anesthesia risk classification using the ASA Physical Status system. By consolidating all pre-surgical data into a single structured document, surgical teams can identify potential complications and ensure every patient meets the criteria for safe anesthesia and surgical intervention.

This template includes dedicated sections for uploading recent laboratory results, EKG and cardiac clearance documentation, and recording baseline vital signs. It also addresses NPO (nil per os) fasting compliance, which is critical for preventing aspiration during anesthesia induction. The built-in consent verification section confirms that the patient has been informed of procedural risks, alternatives, and expected outcomes before the day of surgery.

Designed for ambulatory surgery centers, hospital pre-admission testing departments, and surgical specialty practices, this form streamlines the pre-operative workflow and reduces last-minute cancellations due to incomplete evaluations. It supports compliance with Joint Commission standards and CMS requirements for pre-anesthesia assessments, giving surgical coordinators and anesthesiologists the documentation they need to proceed with confidence.