A preoperative evaluation is the clinician’s full assessment of a patient before noncardiac surgery: the risks, the medicines, and whether to go ahead. Copy the free template, see a hip replacement and a gallbladder surgery example, and check what goes in each part, from the RCRI to the medication plan.
Blank preoperative evaluation template
FreePREOPERATIVE EVALUATION Patient: [Name, age, sex] Date of birth: [Date] Date of evaluation: [Date] Requested by: [Surgeon and surgical service] Evaluating clinician: [Name, credentials; primary care, internal medicine, or pre-admission clinic] Sources: [Patient, family, chart, specialist letters, pharmacy record] PLANNED PROCEDURE Procedure: [Procedure, side, and approach, such as open or laparoscopic] Date and urgency: [Date; elective, time-sensitive, or urgent] Expected stay: [Day surgery, or number of nights] Surgical risk: [Low-risk procedure, or intermediate or high risk] Bleeding risk: [Low to moderate, or high, as the surgical team classes it] Planned anesthesia: [General, spinal or epidural, nerve block, or sedation, if known] HISTORY Conditions: [Each condition, how well controlled it is, and any recent change] Cardiac symptoms: [Chest pain, breathlessness, palpitations, fainting, leg swelling, or none] Past anesthesia: [Previous anesthetics and any problems, such as severe nausea or a difficult airway; family history of anesthesia reactions] Bleeding history: [Easy bruising, nosebleeds, heavy periods, bleeding after surgery or dental work; family history of a bleeding disorder] Allergies: [Drugs, latex, chlorhexidine, with the reaction to each] Substance use: [Tobacco with pack-years, alcohol with amount, cannabis, other drugs] FUNCTIONAL CAPACITY Activity: [What the patient does without chest pain or breathlessness, such as climbing two flights of stairs] Estimate: [4 METs or more, under 4, or unknown; DASI score if used] RISK ASSESSMENT Cardiac: [RCRI with the points counted; active cardiac conditions, or none; BNP or NT-proBNP if measured] Pulmonary and sleep apnea: [Lung disease, smoking, STOP-BANG score and what it means] Frailty and cognition: [For older adults: frailty scale and cognitive screen with scores; delirium risk] Other risks: [Kidney, liver, diabetes control, anemia, nutrition, as relevant] VTE risk: [Score or judgment, weighed against bleeding risk] EXAMINATION Vital signs: [BP, heart rate and rhythm, SpO2, BMI] Heart and lungs: [Murmurs, signs of heart failure, chest findings] Airway: [Mouth opening, Mallampati class, neck movement, teeth and dental work] Other findings: [The surgical site, skin, and anything else relevant] TESTS Results: [Each test with its date and result] Not ordered: [Tests considered, and why they would not change management] MEDICATION PLAN Continue: [Medicines to take as usual, including on the morning of surgery] Anticoagulants and antiplatelets: [Last dose by date and time, bridging or none, and the restart plan] Diabetes medicines: [SGLT2 inhibitor last dose; insulin and other changes] GLP-1 receptor agonists: [Plan under the anesthesia team's current guidance] ACE inhibitors and ARBs: [Hold or continue, and when to restart] Supplements: [What to stop, and from when] ASSESSMENT AND RECOMMENDATIONS Summary: [Age, key conditions, procedure, and overall risk in one or two sentences] Recommendation: [Proceed as planned, optimize first, or delay, with the reasons] Before surgery: [What to treat or adjust, and by when] During and after surgery: [Anesthesia flags, monitoring, troponin if indicated, delirium precautions] VTE plan: [Mechanical or drug prophylaxis, timing, and who orders it] Communicated to: [Patient and family, surgeon, anesthesia or pre-admission clinic, regular clinician, specialists] Signed: [Clinician name, credentials, date and time]
Use it for
Each one follows the template. Use them to judge how much detail every part needs.
Pre-admission clinic, general internist, 17 days before surgery
Elective left total hip replacement for osteoarthritis on Thursday, December 3, 2026, with 1 or 2 nights in hospital. Intermediate-risk procedure, high bleeding risk as the orthopedic team classes it. Spinal anesthesia with sedation planned. Seen on Monday, November 16, 2026, at the surgeon’s request.
68-year-old man. Coronary disease: drug-eluting stent to the right coronary artery for stable angina in 2019, no angina since. Aspirin stopped in 2020 on his cardiologist’s advice, with apixaban alone since. Paroxysmal atrial fibrillation since 2021, on apixaban 5 mg twice daily; no stroke or TIA. Hypertension, controlled. No heart failure, diabetes, or kidney disease. No chest pain, breathlessness, palpitations, or fainting. Past anesthesia: spinal for a knee arthroscopy in 2015, no problems; no family history of anesthesia reactions. Bleeding: none before apixaban, easy bruising since, no excess bleeding after a dental extraction last year. No known allergies. Quit smoking in 2010 after 20 pack-years; 2 drinks a week.
Climbs 2 flights of stairs to his apartment without stopping, and rides a stationary bike for 30 minutes 4 times a week, with no chest pain or breathlessness. Hip pain, not his breathing, limits his walking. More than 4 METs. DASI 38.2, above the cut-off of 34.
Cardiac: RCRI 1, for ischemic heart disease. A hip replacement isn’t one of its high-risk operations, and he has no heart failure, stroke, insulin-treated diabetes, or raised creatinine. No active cardiac condition. NT-proBNP 240 ng/L, under the 300 ng/L threshold for higher risk. Pulmonary: no lung disease. STOP-BANG 3, for blood pressure, age, and male sex: intermediate. No snoring, witnessed pauses, or daytime sleepiness, and a neck of 39 cm, so no sleep study before surgery. Older adult: Clinical Frailty Scale 2, not frail; Mini-Cog 5 of 5; lives with his wife. VTE: high risk after hip replacement, covered by the apixaban restart below.
BP 134/78, heart rate 62 and regular, SpO2 97% on room air, BMI 28. Normal heart sounds, no murmur. Chest clear. No leg swelling. Airway: mouth opening 3 fingerbreadths, Mallampati II, full neck movement, own teeth with a crown upper left. Lower back: no deformity, skin intact. Left hip: painful, with limited internal rotation.
November 16: ECG in sinus rhythm at 62, no ischemic changes, unchanged from 2025. NT-proBNP as above. Hemoglobin normal. Creatinine clearance 84 mL/min; potassium 4.4 mmol/L. Not ordered: an echocardiogram, as he has no heart failure symptoms or murmur and an echo in 2024 showed normal heart function; a stress test, as he has good capacity and no angina, so the result wouldn’t change the plan.
Apixaban 5 mg twice daily: last dose at 8 a.m. on Monday, November 30; none on December 1 or 2, or on the morning of surgery. That gives 2 full days off for a high-bleeding-risk operation, and the 72 hours regional anesthesia guidance asks for before a spinal. No heparin bridging. Restart apixaban 2.5 mg twice daily 12 to 24 hours after surgery, once the surgeon is satisfied with bleeding, then his usual 5 mg twice daily from 48 to 72 hours after surgery. Metoprolol succinate 50 mg and atorvastatin 40 mg: continue, including on the morning of surgery. Losartan 50 mg: last dose on the morning of Wednesday, December 2, so none in the 24 hours before surgery; restart on day 2 if his blood pressure and creatinine are stable. Fish oil and glucosamine: stop from today.
68-year-old man with stable coronary disease and paroxysmal atrial fibrillation on apixaban, for an elective left hip replacement. RCRI 1, good capacity, no symptoms, and a normal NT-proBNP. Recommendation: proceed as planned; no stress test or echocardiogram, as neither would change management. During and after: no routine troponin given the normal NT-proBNP; troponin and an ECG for chest pain, breathlessness, or a new arrhythmia. STOP-BANG 3 flagged to anesthesia: opioid-sparing pain relief and oxygen saturation monitoring the first night. Delirium precautions: glasses and hearing aids, a normal sleep routine, walking on day 1. VTE plan: walking on day 1 and compression devices until apixaban restarts, then apixaban as above, with no separate agent. Communicated: discussed with him and his wife, with a dated medication calendar; sent to the orthopedic surgeon and the pre-admission clinic on November 16, copied to his cardiologist and family physician.
Family medicine clinic, 13 days before day surgery
Elective laparoscopic cholecystectomy for symptomatic gallstones on Tuesday, December 1, 2026, as day surgery. General anesthesia. Low to moderate bleeding risk. The surgeon’s office asked for a preoperative evaluation. Seen on Wednesday, November 18, 2026.
45-year-old woman with 3 episodes of biliary colic since August. The surgical team’s ultrasound shows gallstones with a normal bile duct; liver tests in October were normal. No other conditions. No chest pain, breathlessness, palpitations, or fainting. Past anesthesia: a general anesthetic for wisdom teeth at 19, with severe nausea and vomiting afterward; a spinal for a cesarean at 33, no problems. No family history of anesthesia reactions. Bleeding: no easy bruising, nosebleeds, or heavy periods; no excess bleeding after the cesarean or dental work; no family history of a bleeding disorder. No known allergies. Never smoked; 2 or 3 drinks a week.
Runs 5 km 3 times a week and takes the stairs at work, with no symptoms. Well over 4 METs.
Cardiac: RCRI 1, for intraperitoneal surgery, with none of the 5 patient factors. No heart disease or cardiac symptoms, and excellent capacity. Pulmonary: no lung disease; STOP-BANG 0. Anesthesia: high risk of nausea and vomiting after surgery, as a woman, a non-smoker, and with a past episode. Frailty and cognition: not screened, as she is under 65. VTE: Caprini 3, moderate risk; no personal or family history of clots.
BP 118/72, heart rate 66 and regular, SpO2 99% on room air, BMI 23. Normal heart sounds, no murmur. Chest clear. Abdomen soft, mild tenderness under the right ribs, no jaundice. Airway: good mouth opening, Mallampati I, full neck movement, no loose teeth.
None ordered. No ECG, blood count, kidney tests, clotting tests, or chest X-ray: she is healthy, her bleeding history is negative, and the operation has low expected blood loss, so no result would change the plan. The ultrasound and liver tests are already on file. The hospital does a pregnancy test on the day of surgery, under its own policy.
Levonorgestrel IUD: no change. Acetaminophen as needed and vitamin D: continue. No anticoagulants, antiplatelets, diabetes medicines, GLP-1 receptor agonists, ACE inhibitors, ARBs, or herbal supplements.
Healthy 45-year-old woman, ASA physical status I, for day-case laparoscopic cholecystectomy. Low risk. Recommendation: proceed as planned, with no tests and no medication changes. During and after: high risk of nausea and vomiting after surgery, flagged to anesthesia for prevention with more than one antiemetic. VTE plan: compression devices during surgery and walking the same day, an accepted option at her moderate risk; no anticoagulant. Communicated: discussed with her, and sent to the surgeon’s office and the day surgery unit on November 18.
What is planned, how soon, and how it will be done. The operation and the anesthetic set much of the risk and the medication schedule.
Avoid: Leaving the anesthesia type blank. A spinal or epidural lengthens the time off an anticoagulant, so ask the surgical team if the request doesn’t say.
The conditions and past events that change the operation or the anesthetic: heart, lungs, kidneys, past anesthetics, and bleeding.
Avoid: Ordering clotting tests in place of a bleeding history. In a patient who isn’t on an anticoagulant, the questions find more than a routine INR or PTT.
What the patient can do without chest pain or breathlessness. Good capacity lowers the risk, and usually means no stress test.
Avoid: Counting a walk on flat ground as good capacity. Ask about stairs or hills, and whether symptoms or something else stops them.
Scored risk for the heart and lungs, plus the risks that matter most in older adults, each with what it means for this operation.
Avoid: Scoring only the heart. Lung complications are about as common as cardiac ones after major surgery, and untreated sleep apnea adds risk once opioids start.
A focused exam for surgery and anesthesia: heart, lungs, airway, and the surgical site, with vital signs.
Avoid: Missing a new murmur. A murmur that suggests moderate or worse valve disease needs an echocardiogram before elective surgery, unless a recent one is on file.
The tests that would change management, with their results, and the ones you left out. Healthy patients having low-risk surgery usually need none.
Avoid: Bloods, an ECG, and a chest X-ray for everyone. Before low-risk surgery in a healthy patient they rarely change the plan, and an abnormal result can delay the operation for nothing.
Drug by drug: continue, hold, or change, with the date of the last dose and the restart, so the patient and the ward can follow it.
Avoid: A hold with no restart. When the anticoagulant comes back, and what covers VTE prophylaxis until then, matter as much as the last dose.
Your overall judgment, a clear recommendation, and who now knows it.
Avoid: A recommendation with no owner. Say who restarts the anticoagulant, who orders any troponin, and how the team reaches you.
A routine blood count, ECG, and chest X-ray before a low-risk operation in a healthy adult rarely changes anything. Order each test for a reason you can write down.
A past difficult airway, severe nausea after an anesthetic, or a relative who reacted badly to anesthesia changes the plan. Ask every patient, and pass it on.
Apixaban, rivaroxaban, edoxaban, and dabigatran are paused and restarted on a schedule. Heparin bridging adds bleeding without preventing clots. It is rarely needed for warfarin either, outside very high clotting risk such as a mechanical mitral valve.
Both are easy to overlook on a medication list. An SGLT2 inhibitor taken up to surgery can cause ketoacidosis with near-normal glucose, and a GLP-1 receptor agonist slows stomach emptying. Ask about each by name, including injections for weight loss.
Frailty and cognitive impairment predict complications, delirium, and longer stays after surgery. Screen patients 65 or older, and tell the team what you find.
The surgeon and the pre-admission clinic can’t act on what they don’t see. Send it, and give the patient the medication plan in writing, with dates.
Vero Scribe drafts the preoperative evaluation in your template from the visit, with the patient’s consent, or from your dictation, with each medicine’s last dose and restart spelled out. You review and edit every section, then copy it into your record or export it to Word or PDF. Vero works in 60+ languages.
The planned procedure, its risk, and the anesthesia; the history, including past anesthetics and bleeding; functional capacity; cardiac risk with a score such as the RCRI; lung and sleep apnea risk; frailty and cognition in older adults; an airway exam; tests, and why others weren’t ordered; a medication plan with dates; and a clear recommendation, with the VTE plan and who was told.
The evaluation is your full assessment, kept in your record: history, exam, scores, airway, and your reasoning. The surgical clearance letter is what you send the surgeon from it: the risk estimate, tests, medicines to hold, and recommendations. Write the evaluation, then send the letter, or send the evaluation itself if the surgical team prefers.
Not quite. The anesthesia team does the pre-anesthesia evaluation, before the anesthetic: airway, past anesthetics, fasting, and the anesthetic plan. A medical preoperative evaluation, from primary care, internal medicine, or a pre-admission clinic, assesses and improves the patient’s medical conditions before surgery. The two overlap, and a good medical evaluation gives the anesthesia team much of what they need.
None routinely. A healthy adult having low-risk surgery usually needs no blood tests, ECG, or chest X-ray. Order a test when its result would change management: an ECG for known heart disease before higher-risk surgery, hemoglobin when blood loss is expected, creatinine and potassium with kidney disease or certain medicines, A1c in diabetes. Some guidelines also recommend a BNP or NT-proBNP in older or higher-risk patients.
Give 1 point for each of 6 factors: high-risk surgery, meaning intraperitoneal, intrathoracic, or vascular above the groin; ischemic heart disease; heart failure; stroke or TIA; diabetes treated with insulin; and creatinine above 2.0 mg/dL, or 177 µmol/L. Risk rises with each point. Newer studies give higher event rates for each score than the original paper, so name the score and the estimate you use.
Not usually. Current guidance from anesthesia, surgery, and gastroenterology societies lets most patients continue them. Those at higher risk of a full stomach, such as patients still increasing the dose, on a high dose, or with nausea, vomiting, or bloating, may be asked to take only liquids for 24 hours before or to hold a dose. Follow your anesthesia team’s policy, and record the last dose.
Early enough to act on what you find, often a few weeks before, so there is time to adjust medicines or treat a problem. Many hospitals require the history and physical within a set number of days before surgery, with an update on the day if anything has changed.
Yes. Copy it, or download it as a Word or text file. No account needed.
Capacity for one decision at one time: the information given, the four abilities in the patient’s words, the finding, and who decides next.
The clinician’s assessment after a positive screen: ideation, intent, means, the formulation, and the plan.
Falls history, gait and balance tests, orthostatic BP, medication review, and a plan matched to the risk.
System-by-system exam with normal findings written out, space for abnormal findings, and sensitive exams when indicated.
After a job offer: the job’s demands, relevant history, immunizations, vision and hearing, a job-focused exam and tests, and a fit outcome without the diagnosis.
Pre-anesthesia assessments and patient instructions, drafted for your review.
Complex visits, documents, and follow-up, written from the conversation.
Consultations, patient instructions, and follow-up after surgery.
Vero writes your notes and letters in the templates you choose, so you review instead of type.
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