Room AE200
Harry Medovy House
Winnipeg, MB R3E 0Z2
Tel: (204) 787-8980
Fax: (204) 787-4291
FACULTY OF MEDICINE
Department of Anesthesia
Anesthesia Clinical Assistant Program
ACA:
________________________ Preceptor: ______________________ Date: ______________
Pre-Operative Assessment Evaluation
1. Determines type of surgical procedure, procedural data & duration from the operating room schedule, booking requisition
and consent
2. Reviews submitted information (current and prior medical records, old anesthesia records) for:

Chief complaint & reason for surgical procedure

Past medical & surgical history

Medications & allergies

Laboratory examinations
3. Conduct of patient interview:

Introduces self, states purpose of visit and asks patient if he / she would prefer visitors to step out

Verifies chief complaint and surgical procedure, history of chief complaint

Verifies current medications (prescription, OTC, herbal), including dose and timing

Obtains past surgical & anesthetic history, including history of difficult airway

Review allergies and reactions

Obtains family anesthetic history

Performs review of symptoms (CVS, Pulmonary, Renal, Hepatic, Endocrine and Muscoskeletal)

Specifically rules out GERD, OSA, street drug use, transfusion history, sickle cell disease, steroid use, pregnancy,
alcohol use, tobacco as appropriate

Asks about oral anatomy / pathology (loose and missing teeth, bridges, etc)
4. Conduct of physical examination:

Current height, weight and vital signs (HR, rhythm, RR, B/P, Sa02)

General appearance

Airway examination (cervical spine mobility, TMJ mobility, mouth opening, jaw subluxation, modified Mallampati test,
thyromental distance, teeth & oral structures, survey of neck & submandibular area)

Pulmonary examination

Cardiac examination

Other directed examination
5.
Selects appropriate additional laboratory tests
6.
Speaks with others (family physician, pharmacist, translator etc, if appropriate)
7.
Integrates information, develops & prioritizes a problem list, with the goal of suggesting an anesthetic plan (including type of
anesthesia, monitoring, plan for postoperative analgesia)
8. Discusses anesthetic plan, including alternatives, risks and benefits with the attending Anesthesiologist
9. Discusses aspects of plan, including alternatives, risks and benefits as directed with the patient
10. Documents findings on Preoperative Anesthetic Assessment form
11. Writes appropriate orders in the medical record for co-signature by attending Anesthesiologist
12. Presents information to colleagues or at talk rounds in a focused and succinct manner
Omits items
unable to
establish rapport
Evaluation at: 6 months
Performs with
direct
assistance
10 months
Performs under
direct
supervision
Competent,
safe and
independent
Pre-Operative Assessment Evaluation
Establishes effective rapport with patient
Attentive to patient concerns
 yes
 yes
 no
 no
General comments:
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
Date: ____________________________
Preceptor: ______________________________