Preoperative assessment is the assessment done before surgery, i.e the phase when a patient is prepared for surgery in the time span that includes preparation for, the process of, and recovery from surgery.

Gathering of prompt and accurate initial medical assessment information about the patient before surgery helps to ensure a successful outcome for the patient.

This information gathering is largely a nursing function, with assessments also done by the surgeon, the anesthesiologist or a registered nurse anesthetist (RNA).

What you need to know as a Health Information Management / Medical Records practitioner is that patients for whom surgery is planned have a medical assessment performed before the anesthesia or surgery as required by the JCI Standard AOP.1.5.1, ME 1, and this medical assessment of surgical patients is documented in the medical record before surgery as required by the JCI Standard AOP.1.5.1, ME 2.

Maybe it is good to know what kind of data is gathered in an initial medical assessment before anesthesia or surgical treatment.as required by the the JCI Standard AOP.1.5.1 and what goes into the medical record you keep.

Assessment before aneasthesia or surgery includes :

• observations by the nurse – any unusual reactions or observations recorded in the patient’s medical record and reported to the charge nurse or surgeon at once
• vital signs the morning of surgery and any significant deviation from normal recorded and reported
• a general systems review, noting in particular any new cardiopulmonary developments that place the patient at highrisk during surgery
• a complete physical examination, including laboratory tests and their results recorded in the patient’s record and, if abnormal, reported to the surgeon or their representative – for nonemergency surgery, laboratory tests done about a week before the procedure.

Routine, preoperative laboratory tests often include :

• a chest x-ray
• complete blood count (CBC)
• urinalysis (UA)

Other laboratory tests and examinations will include:

• a metabolic panel
• a toxicology screen, if there is a possibility of alcohol or drug abuse.
• a pregnancy test may be done, to determine what, if any, medication can be used. are performed as needed
• an electrocardiogram is usually obtained for all patients older than 40 years
• blood is drawn for a type and cross match if any possibility exists that a blood transfusion will be needed during surgery
• patient’s weight is documented in kilograms, because dosages of medications, including anesthetics, are usually calculated on the basis of the patient’s kilogram weight
• a visit from the anesthesiologist or nurse anesthetist (RNA) before surgery enables a patient to ask questions that may be troubling him or her and allows the anesthesiologist or RNA to assess the patient based on the assessment findings listed above – “patient management by anesthesiologists is generally highly standardized and includes some of the most robust safety engineering found in health care”, (ACMQ 2010).

As I end this post, I wish to record that this posting brings back memories of my multifaceted experiences, skills acquired and the joy when I worked as a medical assistant (an equivalent to a male nurse) in my start-off, one singular career phase of my life.

References:
American College of Medical Quality, 2010, Medical quality management : theory and practice, 2nd edn, Jones and Bartlett Publishers, Sudbury, MA, USA

Caroline, BR & Mary, TK 2012, Textbook of basic nursing, 10^th edn, Wolters Kluwer Health, Lippincott Williams & Wilkins, Philadelphia, USA

Joint Commission International, 2010, Joint Commission International Accreditation Standards For Hospitals, 4th edn, JCI, USA