Pre-Operative Anaesthetic Assessment Note

Patient [Age in years and gender] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit completely.) Planned Procedure [Type of surgical procedure and urgency level] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit completely.) Background and Functional Status [Description of patient's mobility, independence with activities of daily living, use of mobility aids, and estimated functional capacity in METs if available, including any frailty indicators] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit completely.) Past Medical History [Summary of comorbidities relevant to peri-operative risk, particularly cardiovascular disease, respiratory disease, renal impairment, diabetes, neurological disease and haematological disorders] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit completely.) Previous Anaesthetic History [Previous operations, airway difficulties, postoperative complications or PONV] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit completely.) Medications [List of important medications, especially anticoagulants, antiplatelets, antihypertensives, diabetic medications, steroids and biologics] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit completely.) Allergies [Known allergies and reactions] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit completely.) Airway Assessment [Mallampati class, mouth opening, dentition, thyromental distance, neck mobility and jaw protrusion findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit completely.) Cardiorespiratory Review [Symptoms such as chest pain, dyspnoea, orthopnoea, syncope, exercise tolerance, wheeze or sleep apnoea] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit completely.) Investigations [Relevant investigations including blood tests, ECG findings, echocardiography, imaging or CPET results] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit completely.) Peri-Operative Risk Assessment [ASA physical status classification and commentary on peri-operative risk using clinical judgement supported by recognised frameworks such as RCRI, ARISCAT, SORT or procedure-specific risk tools, discussing main drivers of risk including cardiovascular disease, frailty, poor functional capacity, respiratory disease, renal impairment or bleeding risk, with clear narrative estimate of peri-operative mortality and morbidity risk] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit completely.) Optimisation Required [Additional investigations, specialist referrals, medication adjustments or optimisation measures required before surgery] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit completely.) Postoperative Care [Anticipated level of postoperative care such as ward-based care, enhanced recovery pathway or HDU/ICU requirements] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit completely.) Final Impression [Clear summary of peri-operative risk and suitability for surgery from an anaesthetic perspective] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit completely.)