Preoperative assessment and surgical eligibility protocol

Patient Safety

KEIT DAY HOSPITAL

Preoperative assessment and surgical eligibility protocol

Official Manual of Clinical, Care and Organizational Protocols

1. Document Control Information

2. Scope of Application

This protocol applies to all patients scheduled for elective surgery, with particular attention to aesthetic surgery procedures, surgical dentistry, and procedures performed under general anesthesia or sedation.

3. Responsibilities

• Medical Directorate: Approval of the protocol and verification of its implementation.
• Operating Surgeon: Definition of the surgical indication, required investigations and procedural informed consent.
• Anesthesiologist: Anesthetic assessment, risk stratification and perioperative planning.
• Cardiologist and Other Consultants: Support in selected or complex cases.
• Clinical Coordination: Collection and verification of preoperative documentation.

4. Operating Procedure

• Identify the patient and verify personal details, proposed procedure, anatomical site, and emergency contact information.
• Collect a complete medical history, including previous diseases, previous surgical procedures, allergies, medications, dietary supplements, smoking status, pregnancies, previous thromboembolic events and anesthesia-related complications.
• Assess the surgical and anesthetic risk, including ASA classification, bleeding risk, thromboembolic risk, and the risk of postoperative nausea and vomiting.
• Prescribe standard investigations: complete blood count, coagulation profile, basic biochemistry tests, urinalysis, pregnancy test when indicated, ECG, and additional investigations according to the patient's clinical profile.
• Schedule anesthesiology and cardiology consultations; document any required clinical optimization before final surgical clearance.
• Request procedure-specific investigations: maxillofacial CT scan for rhinoplasty, breast ultrasound for breast surgery, abdominal or abdominal wall ultrasound for abdominoplasty and body contouring procedures, and chest X-ray when clinically indicated.
• Verify the discontinuation or modification of medications and dietary supplements that increase bleeding risk or interact with anesthesia.
• Provide written preoperative instructions regarding fasting, hygiene, admission time, required documentation and the accompanying person.
• Confirm final surgical clearance only after multidisciplinary review of the complete documentation.

5. KEIT Operational Standards

• The informed consent forms and preoperative documentation are also sent to the patient by email before surgery to allow sufficient time for prior review and informed understanding.
• For complex cases, multidisciplinary discussion between the surgeon, anesthesiologist, cardiologist and other specialists is encouraged.
• Preoperative instructions are also reviewed verbally by the clinical coordination team.

6. Records and Documentation

• Preoperative medical record.
• Surgical eligibility checklist.
• Laboratory and diagnostic reports.
• Signed informed consent forms.
• Anesthesiology and cardiology assessments.

7. Review and Updates

Review at least annually or following adverse events, regulatory changes or updates to clinical guidelines.

8. Related Attachments and Forms

• Operational checklists, recording forms, audit sheets and maintenance records applicable to this protocol.
• Any department-specific or equipment-specific technical attachments are referenced in the relevant local operating instructions.

9. Final Approval