SURGICAL CLEARANCE LETTER: PREOPERATIVE RISK ASSESSMENT

[Practice name]
[Address]
[Phone, fax, and secure email]

Date: [Date of letter]

To: [Surgeon's name and surgical service]
Copy to: [Anesthesia or preoperative clinic, and the patient's regular clinician if not you]

Re: [Patient's full name]
Date of birth: [Date]
Seen on: [Date of the preoperative visit]

Thank you for asking me to assess [patient name] before surgery. This letter sets out my estimate of medical risk and my recommendations. It is not a guarantee of safety: the decision to proceed, and the anesthetic plan, rest with you and the anesthesia team.

PLANNED SURGERY
Procedure: [Procedure and side]
Date: [Surgery date]
Urgency: [Elective, time-sensitive, or urgent]
Expected stay: [Same day, or number of nights]
Bleeding risk: [Minimal, low to moderate, or high, as the surgical team classes it]

RELEVANT CONDITIONS
[Each condition, how well controlled it is, and any recent change]
Active cardiac conditions: [None found, or what was found]

FUNCTIONAL CAPACITY
[What the patient does without chest pain or breathlessness, e.g. climbs 2 flights of stairs]
Estimate: [4 METs or more, under 4, or unknown; DASI score if used]

RISK ESTIMATE
Tool and score: [RCRI or another validated tool, with the points counted]
Estimated risk: [Risk level, or events per 100 patients, and the outcome it predicts]

TESTS
Results: [Each test with its date and result, e.g. ECG, NT-proBNP or BNP, A1c, kidney function]
Not ordered: [Tests considered, and why they would not change management]

MEDICATIONS AROUND SURGERY
Continue: [Medicines to take as usual, including on the morning of surgery]
Hold: [Each medicine, the date of the last dose, and when to restart]
Anticoagulant or antiplatelet: [Plan by drug, kidney function, and bleeding risk; after a coronary stent, the cardiologist's advice]
Diabetes medicines: [SGLT2 inhibitor last dose, and any other changes]

RECOMMENDATIONS
Before surgery: [Anything to treat or adjust first, or none]
After surgery: [Monitoring advised, e.g. troponin, and when to call me]

[Patient name] knows this estimate and these recommendations.

Questions: [Your direct phone or secure email]

[Your name, credentials, and specialty]
[License or registration number]
[Signature]