1 Preoperative Preparation and Informed Consent
Learn how individualized preoperative assessment, patient preparation, and informed consent help support safe care before a procedure.
Individualized preoperative assessment
Preoperative assessment and preparation should be individualized. Apply facility policy and the instructions of the responsible clinicians, because specific requirements can vary by patient and procedure.
A draws on the patient interview, relevant medical records, a focused examination, and tests when indicated. Information such as a history of a difficult airway, current diagnoses, and medications can affect the plan of care. Share and document relevant information promptly, and make sure the appropriate surgical and anesthesia clinicians review it.
Selecting preoperative tests
Preoperative testing should be selected for the individual patient and procedure, rather than routinely ordered as the same set for everyone. may depend on the patient's medical history, interview and examination findings, and the type and invasiveness of the planned procedure.
Fasting and medication instructions
Follow preparation instructions tailored to the patient's care plan. If a patient has eaten or drunk during the instructed fasting period, they should tell the care team honestly and promptly rather than conceal it. The team can assess the situation and decide what is safe.
Patients who are unsure whether to take a usual medication should ask the surgical or anesthesia team for instructions instead of guessing or independently changing the plan. They should disclose their medicines, including nonprescription products and supplements, and follow individualized instructions.
Information for
is a communication process, not merely a signature. To support an informed decision about a proposed procedure, the discussion should cover:
The diagnosis, when known.
The nature and purpose of the procedure.
Its expected benefits and material risks.
Reasonable alternatives, including forgoing treatment.
Communicate this information in a way the patient can understand, and document the discussion and decision.
Understanding and voluntary choice
A signed consent form does not by itself establish that the patient understands the procedure or has made a . If a patient says they do not understand or feel pressured, pause before proceeding and arrange for the responsible practitioner to answer their questions and address the concern. The patient should have an opportunity to consider the information and may decline.
If there is uncertainty about the patient's capacity or the appropriate decision-maker, follow applicable law and facility policy.