Pre Operative Assessment By Clinician

A UK NHS-aligned, clinician-driven pre-operative assessment that records objective findings (history, examination, vitals, laboratory results, imaging) and computes an ASA Physical Status grade (I–VI), a composite perioperative risk level, and a set of safety-critical flags. The output is a signed clinician report with an anaesthesia plan suitable for the pre-operative record.

This form is the clinician counterpart to the patient self-report Pre Operative Assessment By Patient: completed by an anaesthetist, surgeon, pre-op assessment nurse, or perioperative physician rather than by the patient. It is aligned with CPOC's Preoperative Assessment and Optimization for Adult Surgery (2021) and the Geeky Medics Anaesthetic Pre-operative Assessment OSCE Guide, and supports shared decision-making under the Montgomery consent standard.

Scoring

Primary instrument: ASA Physical Status (I–VI), with clinician override + reason. Secondary instruments: Mallampati airway class (I–IV), RCRI (0–6), STOP-BANG (0–8), Clinical Frailty Scale (1–9), Fried Frailty Phenotype (0–5), Risk Analysis Index, Mini-Cog cognitive screen, Duke Activity Status Index (DASI), ECOG performance status. Composite perioperative risk (Low/Moderate/High/Critical) is driven by the worst-band finding across instruments.

Where this fits (clinician vs. patient forms)

• This form — objective, clinician-observed findings.
• Pre Operative Assessment By Patient — the patient's own self-reported health data, collected before the clinician visit.

Together they give a fuller pre-operative picture than either alone. This form also overlaps substantially with Pre Anaesthesia Assessment and Anesthesiology Assessment in this source collection — treat all three as near-synonymous clinician-side variants unless a specific context distinguishes them.

Common pitfalls

• Duplicating history already captured on the patient form rather than reviewing and verifying it — the clinician form's value is in objective examination and clinical judgement added to, not duplicating, the patient's self-report.
• Using a stale assessment for surgical clearance — reassess after a meaningful time gap or clinical change between assessment and surgery date.
• Skipping senior review at the High/Critical composite-risk threshold — the banding exists specifically to trigger escalation.

Learn more

• FormExamples: pre-operative-assessment-by-clinician for the full implementation, clinical references, and worked examples.
• Pre Operative Assessment By Patient for the patient self-report counterpart.
• Pre Anaesthesia Assessment, Anesthesiology Assessment for closely related clinician-side assessments.