Preoperative Medical Evaluation Note (Medical Clearance)

Date/Time: [Date and time of evaluation]

Evaluating Clinician: [Name and credentials]

Service/Location: [Clinic/service and location]

Referring Clinician: [Name and service]

Reason for Evaluation: [Preoperative risk stratification for planned procedure]

Planned Procedure: [Procedure name with laterality/site if relevant]

Scheduled Date: [Scheduled date or timeframe]

Urgency: [elective / time-sensitive / urgent / emergent]

Anticipated Anesthesia: [general / neuraxial / MAC / unknown]

Surgeon/Proceduralist: [Name and specialty]

Facility: [Hospital/ASC name]

Estimated Surgical Risk: [low / elevated] (Based on procedure type per ACC/AHA classification.)

Estimated Bleeding Risk: [low / moderate / high]

Executive Summary and Recommendations

(Keep concise and high-signal for surgical and anesthesia teams. Front-load key conclusions and actions.)

• Cardiovascular risk: [Tool used and score with interpretation, e.g., RCRI 2 points (estimated cardiac risk ~6%)]
• Functional capacity: [DASI score with METs estimate / Estimated METs with specific activities documented]
• Active cardiac conditions: [Present: list / None identified]
• Overall perioperative cardiac risk: [low / elevated] - [brief rationale]
• Additional cardiac testing: [Indicated: specify test and clinical question / Not indicated - would not change management]
• Pulmonary risk summary: [Key conditions and control status]
• Disposition: [Proceed as planned / Recommend delay pending: specific optimization steps with target date]
• Key medication actions: [Concise list of critical continue/hold/adjust items with timing]
• Postoperative monitoring: [Telemetry / Troponin surveillance at 24-48h / CPAP / Standard care]

(No medical contraindication identified given available information. Perioperative risk is not zero and final decisions remain with procedural and anesthesia teams.)

History and Perioperative Context

Indication for Procedure: [Condition prompting surgery and current symptoms driving intervention]

Perioperative Review of Systems: [Chest pain/pressure; dyspnea at rest/exertion; orthopnea; syncope/presyncope; palpitations; exercise intolerance; lower extremity edema] (Document pertinent positives and relevant negatives.)

Functional Status: [DASI score with date / Activity description supporting METs estimate / Unknown - state reason and impact on risk assessment]

Recent Acute Events: [MI; stroke/TIA; HF exacerbation; COPD exacerbation with dates and current status / None reported]

Prior Anesthesia Complications: [Difficult airway; prolonged intubation; severe PONV; malignant hyperthermia; perioperative delirium / None known]

Bleeding/Clotting History: [Prior surgical bleeding; transfusions; VTE history; known coagulopathy with dates / None reported]

Past Medical and Surgical History

• Cardiovascular: [CAD/MI with dates; HF type and last EF with date; valvular disease; atrial fibrillation; hypertension; prior PCI/CABG with dates]
• Pulmonary: [COPD/asthma with control status; OSA with CPAP use/compliance; ILD; baseline O2]
• Metabolic: [Diabetes type, regimen, last A1c with date]
• Renal: [CKD stage and baseline creatinine with date]
• Hepatic: [Cirrhosis or chronic liver disease with severity]
• Hematologic: [Anemia with severity/etiology; coagulopathy]
• Neurologic: [Prior stroke/TIA with dates; seizures; cognitive impairment]
• Cardiac Devices: [Pacemaker/ICD type, indication, last interrogation date] (Include only if present.)

Prior Surgeries: [List with years and any perioperative complications]

Medications and Allergies

Current Medications: [Reconciled medication list with dose, route, frequency]

• Anticoagulants: [Agent, dose, indication]
• Antiplatelets: [Agent, indication; stent type and date if applicable]
• Cardiovascular: [Beta blocker; statin; ACEi/ARB; diuretics]
• Diabetes: [Insulin types/doses; metformin; SGLT2 inhibitor; GLP-1 RA with dosing phase and GI symptoms]
• Other perioperative relevance: [Chronic steroids; opioids; benzodiazepines]

Allergies: [Drug and non-drug allergies with reaction type; latex if applicable]

Perioperative Medication Management

Medication	Action	Timing	Notes
[Anticoagulant]	[continue / hold]	[Last dose: date/time; Restart: when hemostasis confirmed per surgeon]	[Indication; CrCl used for timing; bridging decision and rationale]
[Antiplatelet]	[continue / hold]	[Last dose: date/time; Restart: timing]	[Indication; stent history; cardiology coordination if applicable]
[SGLT2 inhibitor]	Hold	[Hold 3-4 days pre-op; Restart when eating normally]	[Reduces perioperative euglycemic DKA risk]
[GLP-1 receptor agonist]	[continue / hold per local protocol]	[Per anesthesia guidance]	[Dosing phase; GI symptoms; aspiration risk coordination]
[Beta blocker]	Continue	[Take usual dose including day of surgery]	[Do not initiate on day of surgery]
[Statin]	Continue	[No interruption]
[ACEi/ARB]	[continue / hold morning of surgery]	[Continue if HFrEF; consider hold if HTN-only and elevated-risk procedure]	[State indication driving decision]
[Insulin]	Adjust	[Bedtime and morning-of dosing plan]	[Explicit dose adjustments or responsible service]

Social History

(Include only if relevant to perioperative risk or planning.)

• Tobacco: [Current/former/never; pack-years; quit date]
• Alcohol: [Quantity; withdrawal risk assessment]
• OSA/CPAP: [Home CPAP use and compliance]
• Functional status and support: [Mobility; home setup; caregiver availability]
• Code status: [If discussed for high-risk procedures]

Physical Examination

Vitals: BP [value], HR [value], RR [value], SpO2 [value], BMI [value]

• General: [Appearance, mobility, frailty indicators]
• Cardiovascular: [Rhythm; murmurs with grade if significant; JVP; peripheral edema]
• Pulmonary: [Work of breathing; breath sounds; wheezes/crackles; baseline oxygen]
• Cognitive: [Orientation; attention; baseline status] (Include if delirium risk relevant.)

Data Reviewed

• ECG: [Date] - [Rhythm; intervals; ischemic or conduction changes]
• Echocardiogram: [Date] - [EF; significant valvular findings]
• Stress testing/coronary imaging: [Date] - [Modality; result]
• Labs: Hgb [value], Plt [value], Cr [value], K [value], glucose [value], A1c [value] ([date]), INR [value] (if applicable)
• Other studies: [PFTs; sleep study; imaging with dates]

(If key data are missing, document what is needed, clinical relevance, and plan to obtain.)

Assessment: Perioperative Risk Stratification

Procedure and Urgency: [Procedure]; [urgency]; surgical risk [low / elevated]

Functional Capacity: [DASI score with METs interpretation / Estimated METs with activities / Unknown - impact on assessment]

Cardiac Risk: [RCRI components and score with interpretation]

Active Cardiac Conditions: [List present conditions / None identified]

Additional Cardiac Testing: [Indicated / Not indicated - state whether testing would change management]

Pulmonary Risk: [Key factors and mitigation plan]

Thrombotic/Bleeding Risk: [Procedure bleeding risk; patient thrombotic risk; anticoagulation strategy summary]

Other Considerations: [Diabetes control; anemia; renal function; frailty/delirium risk]

Plan and Recommendations

Disposition: [Proceed with planned procedure on date / Recommend delay pending specific optimization with target date]. (State conditions that must be met if proceeding.)

• Cardiovascular: [GDMT continuation; beta blocker/statin plan; postoperative monitoring (telemetry, troponin at 24-48h if indicated)]
• Anticoagulation/Antiplatelet: [Restate interruption/restart plan with dates; responsible clinician for bridging; cardiology coordination for stents]
• Pulmonary: [Inhaler optimization; CPAP plan; postoperative monitoring; smoking cessation]
• Diabetes/Metabolic: [A1c optimization if elective; insulin plan or responsible service; SGLT2/GLP-1 instructions; glucose targets]
• Additional Testing/Consultation: [Test; clinical question; how result changes management; target completion date]

Perioperative risks and plan discussed with patient. Recommendations communicated to surgical team.

Follow-up and Contingencies

• Pre-procedure: [Follow-up timing; responsible provider; outstanding items]
• Day-of-surgery: [BP/glucose thresholds for adjustments; criteria for proceeding vs postponing]
• Postoperative: [Monitoring service; medication adjustment responsibility; outpatient follow-up timing]

Signature: [Name, credentials]

Contact: [Phone/pager/email]