Pre-Anaesthetic Evaluation (Preoperative Assessment Note)

Pre-Anaesthetic Evaluation (Preoperative Assessment Note) Patient Identification: [Document patient’s full name, hospital number, date of birth or South African ID number if provided, and gender] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Procedure Details: [Include the planned surgical or procedural intervention, expected date, hospital/clinic location, and the name or discipline of the responsible surgeon/proceduralist] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Medical History: [Summarise relevant chronic illnesses (e.g. HIV, TB, hypertension, diabetes), previous surgical history, known diagnoses, and comorbidities affecting anesthetic risk] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Medication History: [List current medications, including ARVs, chronic disease medication, psychiatric medication, supplements or traditional medicines, and any recent changes in treatment] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Allergies: [Note any documented drug, food or latex allergies, with details about reaction type and severity where known] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Physical Examination: [Include general clinical assessment findings such as weight, height (if relevant), vital signs, cardiovascular and respiratory exam, and any findings influencing anesthetic safety] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Airway Assessment: [Document findings such as Mallampati score, mouth opening, thyromental distance, neck movement, presence of loose/missing teeth or dentures, and any other airway predictors] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Laboratory and Diagnostic Results: [Include relevant blood tests (e.g. Hb, creatinine, glucose, CD4 count if relevant), chest X-ray, ECG, or other investigations used to guide anesthetic risk] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Risk Stratification: [Record ASA physical status classification and any identified risk factors including poor nutritional status, chronic infection, limited functional capacity, or social vulnerabilities] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Anesthetic Plan: [Outline proposed anesthetic technique (e.g. general, spinal, local with sedation), induction and maintenance strategy, monitoring plans, and postoperative care needs (e.g. pain management, high-care admission)] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Consent: [Record details of the informed consent discussion for anesthesia, including discussion of risks, benefits, alternatives (if applicable), and whether the patient had an opportunity to ask questions] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Special Considerations: [Mention any key issues such as NPO compliance, planned surgical position, blood availability, cultural needs, interpreter involvement, or multidisciplinary referrals (e.g. to medicine, cardiology, social work)] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Clinician Signature: [Name of evaluating clinician, designation (e.g. medical officer, anesthetist), and date/time of assessment] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) (Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care. Use only the transcript, contextual notes, or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes, or clinical note, you must not state that the information has not been explicitly mentioned in your output. Leave the relevant placeholder or section blank if it is not explicitly mentioned. Use as many full sentences as needed to capture all the relevant information from the transcript.)