Includes primary diagnoses, surgical history, anesthesia history (prior complications), allergies, and functional status. ASA recommends standardized pre-anesthesia evaluation for all patients.

Cardiology clearance for active cardiac conditions (unstable angina, recent MI, decompensated heart failure, significant arrhythmia). Pulmonology for severe COPD or uncontrolled asthma. Document in chart before case start.

Current ASA guidelines: ≥2h clear liquids, ≥4h breast milk, ≥6h light meal, ≥8h heavy meal or non-human milk. Verify instructions were communicated and patient confirms compliance on day of surgery.

2026: Groups must report ≥6 quality measures including one outcome measure. Common anesthesia measures: MIPS 76 (Prevent Care Composite), MIPS 430 (PONV), MIPS 424 (perioperative temperature management). Confirm measure-eligible cases are flagged.

Emergency cases, patient refusals, and medical contraindications qualify as valid exclusions. Document reason in chart. Incorrect exclusion application is a top audit trigger — each exclusion needs documentation of specific qualifying reason.

Groups required to meet PI category (25% of final score in 2026) unless qualifying for hardship exception. Confirm EHR security risk analysis is completed, e-prescribing rate meets threshold, and patient access measures are on track.

ASA-PS must be documented in pre-anesthesia evaluation. ASA I (healthy), II (mild systemic disease), III (severe but not incapacitating), IV (life-threatening), V (moribund), VI (brain-dead donor). ASA III+ requires additional documentation of specific conditions driving classification.

Flag and communicate: uncontrolled hypertension (SBP >180 or DBP >110 day-of), uncontrolled diabetes (glucose >250), morbid obesity (BMI >40), severe OSAS without CPAP, recent MI or stroke (within 6 months for elective cases).

Warfarin: hold 5 days pre-op; bridge with LMWH if high thrombotic risk (mechanical valve, VTE within 3 months, high-risk AF). DOACs: hold 24–48h (apixaban/rivaroxaban) or 24h (dabigatran, normal renal function) for low-bleed procedures; 48–72h for high-bleed. Document last dose date and confirmation from prescribing physician.

Aspirin 81mg: continue for cardiac patients (ACC/AHA 2022); hold 7 days for others if high-bleed procedure. Clopidogrel/ticagrelor: hold 5–7 days (confirm with cardiologist if recent stent). NSAIDs: hold 5–7 days. Common herbal blood thinners: ginkgo, fish oil, vitamin E — hold 7 days. Metformin: hold 24–48h if contrast expected or renal concerns.

Document which medications patient should take morning of surgery with sip of water (typically: antihypertensives, cardiac meds, thyroid, antiseizure, antidepressants). Which to hold: antidiabetics, ACE inhibitors (optional), ARBs, diuretics, MAOIs. Written instructions to patient ≥48h before surgery.

2014 ACC/AHA guideline: (1) Emergency? Skip workup. (2) Active cardiac condition? Address before elective surgery. (3) Low-risk procedure? Proceed. (4) Functional capacity ≥4 METs without symptoms? Proceed. (5) If <4 METs or unknown AND elevated RCRI, consider further testing only if it changes management. Document each decision point.

Revised Cardiac Risk Index (6 factors): high-risk surgery, history of ischemic heart disease, history of CHF, history of cerebrovascular disease, insulin-dependent diabetes, pre-op creatinine >2 mg/dL. Score 0–1: low risk (<1%); Score 2: moderate (~1%); Score ≥3: high (>3%). Document score in pre-anesthesia note.

Document: Mallampati class (I–IV), mouth opening (>3 cm = adequate), thyromental distance (>6.5 cm = adequate), neck mobility (full vs. limited), BMI, history of prior difficult airway. Any predictor of difficult intubation requires documented backup plan (video laryngoscopy, supraglottic device, awake fiberoptic).

2026 guidance: No routine labs without indication. Recommended: CBC for major surgery/anemia risk; BMP for renal disease/diabetes/diuretics/ACE inhibitors; coagulation panel for anticoagulant use or bleeding history; ECG for cardiac disease or age >65 with symptoms; HbA1c if diabetes and not checked within 3 months.

Call or portal message 48–72h before surgery to confirm: NPO instructions understood, medications held/taken as instructed, no new illness or symptom change since pre-op visit, ride/escort arranged, consent questions answered. Document call in chart with time, staff name, and patient confirmation.

Hold criteria: SBP >180 mmHg or DBP >110 mmHg (uncontrolled HTN); blood glucose >250 mg/dL (uncontrolled DM); SpO₂ <92% on room air; temperature >38°C suggesting acute illness; INR >1.5 for neuraxial cases. Document decision if proceeding despite abnormal values.

Anesthesia consent must document: anesthesia type planned, major risks discussed (death, awareness, nerve injury, aspiration, dental injury), patient questions addressed, interpreter used if applicable, patient/guardian signature obtained. Consent must be signed before any premedication that impairs decision-making capacity.