Insufficient preoperative history and physical, medical clearance and lack of communication with other providers regarding pre-existing conditions can result in postoperative complications.

When medical clearance is warranted, a note from the consulting provider scribbled on a prescription pad indicating “cleared pending labs” is a red flag for you and your office staff.  The optimal process to acquire clearance would be to provide the patient and/or the consulting physician with a standard form indicating the exact medical/clinical information needed for you to make an accurate assessment of the patient as a surgical candidate.  A red flag, such as the situation described above, should be an automatic trigger for staff to be proactive in their follow-up - in this case, to ascertain the results of labs or other tests recommended prior to surgery.

If a preoperative consult is ordered, direct communication with the consulting physician assures that the consultant’s impression of the patient’s condition and appropriateness for surgery is conveyed. This discussion should be documented in the medical record. Consultation reports that are not received should also be an indication for staff to actively follow-up to assure receipt prior to surgery.

It is also prudent to review past medical history with the patient prior to procedures. This process ensures that you have all of the appropriate information needed to assess the patient’s risk for surgery and to institute any pre-procedure measures that might be necessary to improve postoperative outcomes.