MK Pre-Anesthesia Consultation Note

**<u>PRE-ANESTHESIA CONSULT</u>** [Patient name] is a [patient age] y.o. year old [patient gender] presenting to the PAT on [date of presentation] in anticipation of their [procedure name and details] on [date of procedure]. (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.) An AI scribe was used to dictate portions of this note. The patient was made aware of this prior to the start of the consult. They did not have any questions/concerns and they were agreeable to proceed. **OHIP:** [OHIP number] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit line entirely.) **SURGEON:** [Surgeon name and specialty] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit line entirely. Reformat the surgeon's name to a "Dr. [First Name] [Last Name] - [Specialty]" format, cleaning up any extraneous characters or roles like 'Primary'.) **SITE:** [Site of surgery] (Only include if explicitly mentioned in contextual notes, otherwise omit line entirely. The site will be one of: SHB, SHG, or SHC. Print exactly as it appears in the context.) **ELOS:** [Expected length of stay] (Only include if explicitly confirmed in the transcript — either by the physician or by the patient in response to the physician's question. Based on what is stated, select the most appropriate value from: "Same day discharge", "1 day", "2 days", "3-5 days", or "More than 5 days". If ELOS is not explicitly discussed, omit line entirely.) **ALLERGIES:** [List of allergens and reactions] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit section entirely. List each on a new line, combining the allergen and reaction on a single line, separated by a hyphen. Do not include food allergies. If the patient denies any drug allergies, print "No known drug allergies". Do not use bullet points.) **DIAGNOSIS/REASON FOR SURGERY:** [Diagnosis for surgery and brief summary] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit section entirely. Do not use bullet points. State the primary diagnosis first, followed by a colon and a brief summary in one or two sentences outlining relevant details such as previous treatments or history. Do not include diagnosis codes.) **ANESTHETIC PROBLEM LIST:** [Synthesized list of all relevant medical problems with anesthetic implications] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise print "#". Synthesize a comprehensive list of all relevant medical issues from the entire transcript, contextual notes, and clinical note, including any positive findings from the Review of Systems, positive surgical history, and social history such as excessive substance use or chronic opioid use. For each problem, create a heading starting with "#". Under each heading, use bullet points "-" to detail the severity, current management including medications and surgeries, and any other relevant clinical details. If a patient is on chronic opioids, create a specific "Chronic Opioid Use" problem detailing the daily dose and MME. Do not calculate an MME for drugs other than opioids. If there is no history of opioid use, do not mention opioid use. Do not include explicit "Anesthetic Implications" subheadings. Bold any medications mentioned. If an echocardiogram is mentioned in the transcript or notes, include a brief summary of its findings under the relevant problem item, or create a new problem item for it if one does not exist. Ensure there is one blank line between each problem item.) **FUNCTIONAL CAPACITY:** [Description of patient's maximum exercise tolerance] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit line entirely. Write in paragraph format.) [Summary of functional capacity symptoms including exertional chest pain, dyspnea, PND, orthopnea, or leg edema] (Only include if the patient has a relevant history such as heart failure as mentioned in transcript, contextual notes or clinical note, otherwise omit line entirely. Write in paragraph format.) **ROS:** Review of systems was otherwise grossly normal. [Confirmation that anesthetic questionnaire was reviewed] (Only include if anesthetic questionnaire was reviewed as mentioned in transcript, contextual notes or clinical note, otherwise omit line entirely. If reviewed, print "The patient's anesthetic questionnaire was reviewed and no further issues were found beyond those identified above.") [Confirmation that patient was asked about outstanding health issues] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit line entirely. If confirmed, print "Patient was asked if there were any outstanding issues with their health which they denied.") **SURGICAL HISTORY:** [List of past surgical procedures with laterality and date] (Only include if explicitly mentioned in transcript or contextual notes, otherwise omit section entirely. List as bullet points, summarizing each procedure on one line. If the patient denies ever having anesthesia, omit this placeholder entirely.) [Summary of prior anesthetic experience] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit line entirely. If the patient has had prior anesthetic problems, describe them here and ensure a corresponding item is in the Anesthetic Problem List. If the patient denies any prior anesthetic problems, print "Patient has had prior anesthesia without any issues." If the patient denies ever having had an anesthetic, print "Patient denies ever having had an anesthetic.") [Family history of anesthetic problems and MH or pseudocholinesterase deficiency] (Only include if explicitly confirmed in transcript or contextual notes, otherwise omit line entirely. If no family history of anesthetic problems and no personal or family history of MH or pseudocholinesterase deficiency is confirmed, print "No family history of problems with anesthetics. No personal or family history of MH or pseudocholinesterase deficiency." If a positive family history of anesthetic problems or a personal or family history of MH or pseudocholinesterase deficiency is confirmed, omit this line and ensure a corresponding item is added to the Anesthetic Problem List.) **MEDICATIONS:** [List of current outpatient medications] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit section entirely. List each medication on a new line. Do not use bullet points. List the generic name if possible and the route of administration. Do not include doses, except for opioids. For opioid medications, include the dose, calculate the cumulative daily dose, and convert it to daily oral morphine equivalents (MME/day). For any blood thinners including apixaban, rivaroxaban, warfarin, ASA, and edoxaban, capitalize and bold the name, e.g. "**APIXABAN**". Ensure each medication is accounted for under a corresponding item in the Anesthetic Problem List.) **SOCIAL HX:** [Patient's social history including smoking, alcohol, recreational drug use, occupation, and other relevant personal details such as language barriers] (Only include if explicitly mentioned in transcript or contextual notes, otherwise omit section entirely. Write in paragraph format. If use of any substance is excessive, ensure a corresponding item is added to the Anesthetic Problem List.) **LABS:** [Summarized lab results] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit section entirely. Synthesize all lab results into a concise narrative format. Group results by date on separate lines, with the date formatted as DD Month YYYY. For each date, list the relevant results using common abbreviations such as Hb, Hct, Plts, Na, K, Cr and their values. Do not include table headers. If a lab value is marked with (H) for high or (L) for low in the source, format the value and the marker in bold, e.g. **150 (H)**, and retain the marker.) **MOST RECENT INVESTIGATIONS:** [Summary of relevant investigations] (Only include if investigations such as imaging, echo, ECGs, MRIs, CTs, or Cath results are explicitly mentioned in transcript, contextual notes or clinical note, otherwise print "No relevant investigations were found." For each investigation, create a bullet point starting with "#" and include the investigation type, date formatted as DD Month YYYY, and key findings. Only display investigations that were performed or are available. Do not include investigations that were not mentioned.) **PHYSICAL EXAM:** [Patient's height, weight, and BMI] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit line entirely. Format as "Height [value] cm, Weight [value] kg, BMI [value]". Convert from imperial units to metric if necessary. Only include BMI if it is explicitly stated in the transcript, contextual notes or clinical note. Round height and weight values to the nearest whole number.) [Vitals including blood pressure, heart rate, and SpO2 saturation] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit line entirely.) Airway: [Airway assessment summary] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise print "likely easy".) [Details of any previously documented airway] (Only include if a previous airway is documented in transcript, contextual notes or clinical note, otherwise print "No previous airway documented".) Dental: [Dental exam findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise print "grossly normal".) Cardiovascular: [Cardiovascular exam findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise print "grossly normal".) Respiratory: [Respiratory exam findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise print "grossly normal".) Neurologic: [Neurologic exam findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise print "grossly normal".) Other: [Other physical exam findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise print "grossly normal".) **ASSESSMENT AND PLAN:** [Patient summary including optimization status, procedure name, date of procedure, and surgeon name] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit section entirely. Print "In summary, [patient name] is **OPTIMIZED** for [procedure name and details] on [date of procedure] with [surgeon name]." by default. Only print "**NOT OPTIMIZED**" in place of "**OPTIMIZED**" if explicitly stated in the transcript. Use the same surgeon name and format as in the SURGEON section.) [Anesthesia and fasting discussion summary] (Only include if the overall conduct of anesthesia and/or fasting guidelines were reviewed with the patient as mentioned in transcript, contextual notes or clinical note, otherwise omit section entirely. If confirmed, print "In the clinic today, the overall conduct of anesthesia was reviewed with [patient name]. The CAS fasting guidelines were discussed.") [Medication continuation and hold instructions] (Only include if medication instructions were explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit section entirely. If the patient is not on any regular medications, print "Patient is not on any regular medications." If the patient is asked to continue all medications with no holds, print "I've asked [patient name] to continue all of their regular medications up until and including the day of surgery." If there are medications to hold, print "I've asked [patient name] to continue all of their regular medications up until and including the day of surgery with the exception of:" and list each medication to hold on a new line starting with "#", including the medication name, hold duration, and last day the medication can be taken in the format "#[Medication], hold for [duration], last day [date]". For specified blood thinners including apixaban, rivaroxaban, warfarin, ASA, and edoxaban, make the medication name capitalized and bold.) [Anesthetic types and risks reviewed] (Only include if anesthetic types were explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit section entirely. If confirmed, print "We reviewed the following possible anesthetic types and associated risks." followed by each anesthetic type on a new line starting with "#". For GA, mention risks of sore throat, nausea and vomiting, dental damage, and remote chance of cardiovascular and respiratory complications. For Neuraxial, mention risks of PDPH at 1%, infection at 1 in 1000, temporary nerve damage at 1 in 10000, permanent nerve damage at 1 in 250000, and failed spinal at 1 in 100. For Regional, mention risks of nerve damage, infection, and bleeding. Do not include specific numbers for risks other than those outlined above.) [IV access plan] (Only include if access was explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit section entirely. If only pre-op IV insertion was discussed, print "We spoke about the need for pre-op IV insertion." If additional access such as second IVs, arterial lines, or central lines were also discussed, print "In terms of access, we spoke about the need for pre-op IV insertion as well as possible:" and list the additional access items on new lines starting with "#".) [Items to bring on the day of surgery] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit section entirely. Print "I've also asked [patient name] to bring the following on the day of surgery:" followed by a list of items on new lines starting with "#".) [Pre-operative tests and follow-ups ordered] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit section entirely. Print "I have ordered the following additional tests, pre-operatively." followed by a list of items on new lines starting with "#".) [Pre-operative medications ordered] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit section entirely. If preoperative medications were ordered, print "As for pre-op I've gone through the liberty of ordering the patient:" and list each medication on a new line starting with "#", including dose and route. If no preoperative medications were ordered, print "I did not order any preoperative medications for this patient.") [Same day discharge post-operative instructions] (Only include if the patient's ELOS is confirmed as "Same day discharge" in transcript or contextual notes, otherwise omit section entirely. If confirmed, print "In the event that they are discharged home post-op, we spoke at length that [patient name] is not to drink any alcohol, use other recreational drugs, drive or use heavy machinery for 24 hours. They will need to have a responsible adult to take them home and supervise them for a period of 24 hours post-op.") [Patient questions and anesthesiologist decision statement] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit section entirely. If confirmed, print "[Patient name]'s questions were solicited and answered. [Patient name] was made aware that the anesthesiologist on the day of surgery will make the final decision as to the anesthetic plan.") The patient was agreeable to proceed. (Format all dates as DD Month YYYY, e.g., 07 April 2026. If a day is not available, use Month YYYY. For events over 10 years ago, use the year, approximate years ago, or "remote" if unknown.)