# ANAESTHETIC PRE-ASSESSMENT
Copy and paste this template into a PROGRESS NOTE in the patient's ECR record. Complete the assessment in the Progress Note. Make sure the time and date are correct.
The patient demographics are automatically present in NIECR, as are any lab results.
For a more precise specification of MedicalMarkDown, please see

---
ASSESSING_ANAESTHETIST:
PROCEDURE:
DATE_OF_SURGERY:

AGE:
GENDER:
SMOKING_STATUS:
ALCOHOL INTAKE:
BP:
HR:
SpO2:
HEIGHT:
WEIGHT:
BMI:

---
## Previous_anaesthesia:
DETAILS:
Complications:

---
## AIRWAY_ASSESSMENT:
AIRWAY:
MP:
DENTITION:
MOUTH_OPENING:
OTHER:

## RENAL
DETAILS:
eGFR:
DIALYSIS:
FISTULA:
LINES:

---
## CVS:
- [ ] IHD
- [ ] PREV_MI
- [ ] CHF
- [ ] SIGNIFICANT VALVULAR DISEASE
- [ ] PACEMAKER

DETAILS:
ECG:
ECHO:
OTHER:

## RESPIRATORY
- [ ] COPD
- [ ] ASTHMA
- [ ] OSA

MRC DYSPNOEA SCALE:
OTHER:

### STOPBANG SCORE HIGH RISK 3 or more
- [ ] SNORE
- [x] TIREDNESS
- [ ] OBSERVED STOPPING BREATHING
- [x] PRESSURE(BLOOD)
- [x] BMI>35
- [ ] AGE>50
- [ ] NECK >40cm CIRCUM
- [ ] GENDER MALE

CXR:
PFTS:
OTHER:

---
## GI/OTHER
DETAILS:

---
## FRAILTY
CLINICAL FRAILTY SCORE:
NYHA ACTIVITY SCORE:
DASI SCORE:

---
## INVESTIGATIONS
SEE INVESTIGATIONS DATED:
IV_Fe:
- [ ] INDICATED
- [ ] ADMINISTERED
- [ ] REQUESTED

OTHER:

---
## MEDICATIONS
SEE MEDS LIST
ANY MEDS STOPPED?:
ANY MEDS STARTED?:
RECREATIONAL/HERBAL:

## ALLERGIES/INTOLERANCES
DETAILS:
WHAT_HAPPENS:

---
## Overall Assessment / Risks Discussed / Anaesthetic techniques:
DETAILS:

RISK:
P-POSSUM:
SORT:
ASA:

WRITTEN INFORMATION GIVEN:
- [ ] EPIDURAL
- [ ] SPINAL
- [ ] GA
- [ ] TRANSFUSION
- [ ] OTHER

DETAILS:

---
## PLAN: (delete inapplicable)
- FIT TO PROCEED
- FURTHER Ix THEN RV BY ANAESTHETIST (CLINIC/NOTES)
- FURTHER Ix THEN REPEAT MDM
- POSSIBLE FOR LD, NOT OUT-OF-HOURS
- UNFIT FOR ANAESTHETIC
- ITU/HDU REQUIRED

NOTE: Any patient deemed *very high risk*, *LD but not OOH* or *UNFIT* needs to be discussed at joint meeting between Anaesthesia, Surgery & Nephrology.

DATE:
eSIG: