Surgery Clearance Form Template
Document medical clearance for surgery — with all the clinical detail the surgical team needs.
Surgery clearance confirms that the patient's current health status is acceptable for the planned procedure and anesthesia. This form gives primary care providers and specialists a structured way to document their assessment and communicate it to the surgical team.
The template covers the patient's identifying information, the planned surgical procedure, the clearing provider's assessment of relevant conditions, current medications and their management around surgery, findings from the pre-operative examination, any identified risks and recommendations, and the clearance determination with signature.
A well-documented clearance reduces pre-operative delays, helps anesthesia teams plan appropriately, and ensures the surgical team knows about every relevant condition before the first incision.
Surgical clearance is a medical opinion that a patient is fit to undergo the planned procedure and anesthesia. It's typically provided by the patient's primary care physician, a cardiologist for cardiac conditions, or another specialist based on the patient's health profile.
Uncontrolled hypertension or diabetes, significant cardiac or pulmonary disease, recent MI or stroke, sleep apnea, bleeding disorders, and active infections. The anesthesiologist or surgeon determines when specialist clearance is needed.
For elective procedures, 2 to 4 weeks before surgery is typical. This allows time to address any identified concerns. Last-minute clearances under time pressure lead to missed issues.
Blood thinners are often held pre-operatively. Insulin and diabetes medications may need adjustment. Some supplements like fish oil, vitamin E, and aspirin affect bleeding. The clearing provider should address these specifically in the form.
Yes. If the patient's condition poses unacceptable risk for the planned procedure, the clearing provider can withhold clearance and recommend optimization first. The patient, surgeon, and clearing provider should align on an acceptable plan before proceeding.
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