Pre-Anesthesia Evaluation Note

Patient: [Full name]; MRN: [MRN]; DOB: [DOB]

Procedure: [Procedure name with laterality/site if applicable]; Surgeon/Proceduralist: [Name]; Scheduled: [Date] at [Time]

Planned Anesthesia: [GA / regional / MAC / combined technique]; Status: [elective / urgent / emergent]

Evaluator: [Clinician name and credentials]

Information Sources: [patient interview / chart review / family or surrogate / outside records]; Limitations: [none / language barrier / altered mental status / unavailable records / other]

Summary: [One-line pre-anesthesia summary including procedure, planned technique, key risk factors, and ASA class]

Anesthesia-Focused History

[Brief reason for procedure and anesthesia-relevant symptoms] (2–5 sentences. Address chest pain, dyspnea, orthopnea, syncope, recent URI, cough, fever, or other symptoms that may impact anesthesia risk. Note any interval changes since last evaluation including new diagnoses, medication changes, hospitalizations, or new test results. If this is an update to a prior anesthesia clinic evaluation, state this is an interval re-assessment and reference the prior evaluation date.)

Prior Anesthesia History

• Prior anesthetics: [yes / no / unknown] (If records reviewed, summarize key airway findings including device used, ease of mask ventilation, grade of view, adjuncts required.)
• Airway history: [Difficult mask ventilation or intubation, video laryngoscopy requirement, awake intubation, LMA use, dental issues, limited neck mobility, prior radiation, tumors, or none reported]
• Peri-anesthetic complications: [Severe PONV, aspiration, awareness/recall, anaphylaxis, bronchospasm, laryngospasm, unplanned ICU admission, postoperative ventilation, malignant hyperthermia concern, pseudocholinesterase deficiency, prolonged paralysis, or none reported]
• Family anesthesia history: [Malignant hyperthermia, pseudocholinesterase deficiency, or none reported]

Medical History

(List anesthesia-relevant comorbidities with brief qualifiers such as severity, control, and last relevant event.)

• Cardiac: [CAD / heart failure / arrhythmias / valvular disease / pacemaker or ICD / pulmonary hypertension / none] (Include severity, recent symptoms, device dependence, last interrogation if applicable.)
• Pulmonary: [COPD / asthma / home oxygen / recent exacerbation / OSA or OHS / none] (Include baseline oxygen needs, CPAP use and adherence.)
• Neurologic: [stroke or TIA / seizure disorder / neuromuscular disease / none] (Include last event and current control.)
• Renal/Hepatic: [CKD stage and dialysis schedule / cirrhosis severity / none] (Include most recent dialysis, ascites or encephalopathy if relevant.)
• Endocrine: [diabetes type and control / thyroid disease / obesity / none] (Include HbA1c and insulin regimen if relevant.)
• Hematologic: [anemia / coagulopathy / sickle cell disease / VTE history / none] (Include last event and anticoagulation status.)
• GI/Aspiration risk: [GERD / gastroparesis / obstruction / pregnancy / none] (Include symptom control.)
• Substance use: [chronic opioids / buprenorphine / methadone / benzodiazepines / alcohol use disorder / none relevant] (Include tolerance or last use if clinically relevant.)

Functional status: [Estimated exercise tolerance] (Quantify with practical activities such as flights of stairs or walking distance; include limiting symptoms. If unavailable, document reason.)

Surgical history relevant to anesthesia: [Prior airway or ENT surgery / cervical spine surgery / back surgery affecting neuraxial feasibility / none relevant] (Include only if it meaningfully affects airway or neuraxial approach.)

Medications and Allergies

Home medications: [List home medications with doses and timing, or state "reviewed medication list in chart"] (Include peri-procedural hold/continue instructions when part of anesthesia workflow.)

• Anticoagulants/antiplatelets: [Agent, indication, last dose date/time, periprocedural plan]
• Diabetes medications: [Insulin regimen and last doses; oral or injectable agents; perioperative adjustment plan]
• Chronic opioids/buprenorphine/methadone: [Dose, schedule, perioperative plan]
• Chronic steroids: [Agent, dose, duration; stress-dose plan if applicable]
• Beta-blockers and critical cardiac medications: [Continue/hold plan]

Allergies: [List each agent with reaction type; include latex, adhesive, or chlorhexidine if relevant] (If none: NKDA, patient-reported or chart-verified. Do not infer reactions; document as stated.)

NPO Status

• Last clear liquids: [Date/time]
• Last solids/non-clear intake: [Date/time]
• Special items: [Gum/candy, tube feeds, GLP-1 agonist timing per local policy, or none]

(If patient is not NPO per guidelines or status is uncertain, document risk mitigation plan such as delay, rapid sequence induction, gastric ultrasound, or other approach.)

Advance Directives

[Advance directives/DNR status and location in chart; peri-procedural plan to continue, suspend, or modify; when baseline directives will be reinstated] (Only include this section when directives or treatment limitations exist.)

Physical Examination

Vitals: BP [value], HR [value], RR [value], SpO2 [value] on [room air / supplemental O2], Temp [value]; Height [value], Weight [value], BMI [value]

Airway assessment: Mallampati [I / II / III / IV]; mouth opening [adequate / limited] ([measurement if available]); thyromental distance [measurement or adequate / short]; neck mobility [full / limited]; dentition [normal / loose teeth / dentures / missing]; facial hair or features [describe if relevant]; OSA [present / absent / suspected]

Airway impression: [low / possible / high] difficulty anticipated. Planned approach: [mask and LMA / direct laryngoscopy / video laryngoscopy / awake strategy]. Backup plan: [Outline rescue plan and equipment]

Cardiopulmonary: Heart [rate, rhythm; murmurs if present]; Lungs [work of breathing; clear / wheeze / rales]; Baseline oxygen requirement [none / device and flow]

Additional exam: [Back exam for neuraxial planning / vascular access assessment / baseline neurologic deficits relevant to regional anesthesia] (Include only when relevant to planned technique.)

Data Reviewed

• Laboratory studies: [CBC / BMP / coagulation / pregnancy test / type and screen] — [date] — [anesthesia-relevant interpretation]
• Cardiac studies: [ECG / echocardiogram / stress test / catheterization / device interrogation] — [date] — [key findings relevant to anesthesia]
• Pulmonary studies: [CXR / PFTs] — [date] — [key findings]
• Specialty consultations: [Cardiology / Pulmonology / Hematology / Pain] — [date] — [clearance status and key recommendations]
• Pending data: [List pending items and anticipated availability; state whether proceeding is appropriate and contingency plan]

ASA Physical Status

ASA [I / II / III / IV / V / VI] [E if emergent] (Provide brief justification when ASA III or higher.)

Anesthetic Plan

Technique: [GA / regional / MAC / combined] (For MAC, state intended depth and acknowledge potential conversion to GA. For regional, specify type, laterality, and catheter vs single-shot.)

Airway strategy: [Nasal cannula / facemask / LMA / ETT]; [spontaneous / controlled] ventilation; difficult airway equipment plan [describe]; extubation considerations [awake / deep / special precautions]

Monitoring and access: Standard monitors [plus arterial line / central venous access / large-bore IV / TEE / none beyond standard]

Special considerations: [Induction/maintenance strategy for high-risk conditions; fluid and hemodynamic goals; temperature management; blood products and patient preferences or restrictions] (Include only when relevant.)

Postoperative plan: Disposition [PACU / ICU / stepdown / telemetry]; multimodal analgesia [list agents and regional techniques if applicable]; PONV prophylaxis [agents and strategy]; [opioid tolerance plan if applicable]

Anesthesia Consent Discussion

• Decision-maker: [Patient / surrogate]; capacity: [has capacity / lacks capacity]
• Interpreter: [Language and interpreter ID or method] (Include if used.)
• Discussion: Proposed technique(s), material risks (common and serious) tailored to patient and procedure, benefits, alternatives including different techniques and possible conversion, and postoperative pain plan were discussed. Patient was given opportunity for questions and questions were answered.
• Outcome: [Agrees to proceed / Declines / Requests modification]; [Document specific concerns, limitations, or refusals]
• Elevated risk discussion: [Document patient-specific elevated risks discussed and patient/surrogate understanding] (Include when applicable.)

Attestation

I reviewed the medical record, interviewed and examined the patient, reviewed pertinent tests and consultations, assigned the ASA Physical Status, and formulated the anesthetic plan as documented above.

Signature: [Name, credentials] — Date/Time: [Date] [Time]

(Missing information handling: NPO status, allergies, airway assessment, ASA PS, anesthetic plan, and consent discussion must always be present. If required information cannot be obtained, document "unable to obtain due to [reason]" with mitigation plan. For pending data, document what is pending and contingency plan. Do not infer NPO times, allergy reactions, or airway findings. ASA PS must be explicitly assigned by the clinician.)