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Pre-Operative Documentation

Updated: May 23, 2022

The pre-operative stage is a relatively long period. It starts from the moment the patient is informed about the need for a surgical intervention up until they reach the operating theatre. During this period, the goal is to prepare the patient in a way that reduces the risk of complications both during and after surgery. Having the correct pre-operative documentation plays a major role in achieving this.

In these notes, we’ll be going over the required pre-operative documentation and their relevance to improving patient safety as well as helping the surgical staff.


What is pre-operative documentation?

As we mentioned above, the goal in the pre-operative phase is to identify any risk factors that might complicate the surgery or the recovery and then implement strategies to reduce them. The pre-operative documentation is basically a set of forms that reminds the surgical staff about all the things they need to consider before performing a surgical intervention on a patient. Moreover, having everything written and signed reduces the likelihood that someone forgets an important detail about the patient such as an allergy or a chronic condition.

For most hospitals, the required pre-operative documents are:

  1. Medical History

  2. Physical Assessment

  3. Informed Consent

  4. Pre-Op Ward Checklist

  5. Who Theatre Safety Checklist

Pre-Operative Documentation: Medical History

Obtaining a thorough medical history is vital when preparing a patient for surgery, as it will identify any undiagnosed diseases or inadequately controlled chronic conditions. The pre-op medical history has to include:

  1. Past and current medical conditions

  2. Past surgeries

  3. Medical and surgical family history

  4. Social aspects (ie. tobacco use, recreational drugs or alcohol)

  5. Past and current allergies or unusual reactions to drugs

  6. Any knowledge of complications with anaesthesia (both the patient and family)

  7. Current medications or herbal supplements

If the patient is a child, then you will also need to obtain a birth history including:

  1. Prematurity at birth

  2. Perinatal complications

  3. Congenital chromosomal or anatomic malformations

  4. Recent infections

Pre-Operative Documentation: Physical Assessment

All patients undergoing surgery require a pre-anaesthesia physical assessment to identify any potential complications related to the anaesthetic and intubation. Typically this would include an assessment of the airway, respiratory system and cardiac system, along with the vital signs. Moreover, additional investigations will be needed if the patient mentions other conditions during the medical history or if there are any abnormal findings in the regular physical assessment.

Once completed, the physician in charge needs to compile a report of the findings and include it in the patient’s file.

Pre-Operative Documentation: Lab work

A standard set of blood tests are typically done to evaluate the patient’s physiological status before the surgery. The results also help the surgical team anticipate future interventions, such as the need for a blood transfusion if a large volume of blood is lost in surgery or additional IV fluids if the patient has an electrolyte imbalance. The most commonly done tests include:

  1. Complete Blood Count

  2. Blood Typing and Cross Match

  3. INR & aPTT

  4. Electrolytes & Creatinine

  5. Fasting Glucose if the patient is diabetic

  6. ECG

Certain surgeries might require the patient to attend to radiography scans prior to the surgery.

Pre-Operative Documentation: Informed Consent

Another vital document is the consent form, which is a legally binding agreement between the patient and the surgical team. By filling out this form, the patient is giving the surgeon and his team permission to perform the surgical intervention. But in reality, the consent form offers much more than that.

For the form to be legal, the surgeon must specify several details to the patient, these include:

  1. The type of surgery

  2. Why it is necessary and its benefits

  3. Associated risks and complications

  4. Expected organ removal or donation

  5. Expected deformities

  6. Alternative treatment options

Having discussed all these points, the patient would be in a position to make a well-informed decision about their health. And they can decide if they’d like to go ahead with it or not. If they accept to do the surgery, they would also be accepting the terms that come along with it. Moreover, specifying all these details prohibits the surgical team from performing any additional surgical interventions without the patient’s knowledge.

Moreover, the patient’s signature is only valid if the patient is over 18 years of age, mentally capable, and signs out of free will. If a patient is under 18 years of age or has an altered mental status, their next of kin will take the responsibility to sign for them under the same conditions. But if their signature has been coerced, then the form is no longer valid.

Lastly, depending on the hospital, additional consent forms might be necessary for patients receiving anaesthesia, blood products, radiation, organ donation and biopsies. However, in most cases, all of these points would be included in the same consent form.

Pre-Operative Documentation: Ward Checklist

Once all the above documentation has been completed and the day of the surgery arrives, the ward nurses have to complete a pre-op ward checklist. This ensures that the patient is ready to be taken into theatre, meaning that:

  1. An ID bracelet has been placed around the patient’s wrist

  2. An Allergy bracelet has been placed if the patient is allergic to anything

  3. The name of the surgery is clearly stated on the checklist, matches the consent form and the patient agrees

  4. The site of the surgery has been marked on the patient, written on the checklist and matches the site on the consent form

  5. All make-up, clothes and jewellery have been removed and the patient is in a hospital gown

  6. Dentures, hearing aids or removable prosthetics have been removed

  7. All the required documentation is available (consent, medical history, physical assessment, lab work)

  8. The patient has been starved for a minimum of 6 hours

  9. Any pre-op medication has been documented

  10. Any chronic conditions have been listed

  11. The latest vital signs have been charted

Pre-Operative Documentation: Theatre Checklist

Following the ward checklist, the patient is taken into theatre and before being given anaesthesia and starting the surgery there is one more checklist that needs to be done. This is known as the Surgical Safety Checklist and it is a universal checklist issued by the World Health Organisation.

As you can see below the checklist has three stages, the first set of questions must be completed before giving the patient anaesthesia. The second part has to be filled before the surgeon cuts the skin, and the final part is filled in after the surgery is complete but before the patient leaves the operating theatre.

who surgical checklist


  1. Zambouri A. (2007). Preoperative evaluation and preparation for anesthesia and surgery. Hippokratia11(1), 13–21.


  3. O’Donnell F. T. (2016). Preoperative Evaluation of the Surgical Patient. Missouri medicine, 113(3), 196–201.

  4. Alpendre, F. T., Cruz, E., Dyniewicz, A. M., Mantovani, M. F., Silva, A., & Santos, G. (2017). Safe surgery: validation of pre and postoperative checklists. Revista latino-americana de enfermagem, 25, e2907.

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