Preoperative Assessment Documentation Audit

Free projects are complete and ready to use. Paid projects can also be adapted to your local requirements. This project uses a fixed Lazomis clinical configuration of 42 audit criteria across cohort and procedure context, patient context and communication needs, anaesthetic and surgical risk documentation, medicines, allergies and perioperative prescribing, observations, measurements and investigations, optimisation and prehabilitation, safety checks and pathway planning, and escalation, communication and readiness. Data collection, dashboards, findings, improvement planning, re-audit and every output are included at no cost.

• Preoperative assessment nurses, anaesthetists and surgical teams
• Perioperative medicine, frailty and prehabilitation services
• Clinical pharmacists and medicines optimisation teams
• QI, clinical governance and trainees needing ARCP-ready evidence

• Measure whether procedure, urgency, anaesthetic plan and assessment context are documented
• Review documentation of anaesthetic risk, comorbidity, frailty and functional status
• Review medicines, allergies, anticoagulation, diabetes medicines and perioperative medication planning
• Review investigations, abnormal-result action, optimisation, safety checks, escalation and readiness
• Generate governance-ready and ARCP-ready evidence

• Anonymised case number, care setting, specialty, procedure category and pathway urgency
• Age band, ASA grade, assessment mode, assessor role and timing before procedure
• Comorbidity burden, frailty, polypharmacy, anticoagulation and diabetes flags
• Optimisation needs, investigations required, assessment outcome and delay or cancellation
• 42 fixed audit criteria (Yes / No / Not applicable)
• Free-text learning points

• Live dashboard
• Audit report (Word)
• Executive summary (Word)
• Excel workbook
• PowerPoint presentation
• Conference poster
• ARCP evidence summary

• Designed to use anonymised or pseudonymised audit identifiers.
• This tool supports, but does not replace, clinical judgement.
• Local policy, formulary and specialist advice should be followed.
• Organisations remain responsible for local governance arrangements.
• This tool supports clinical audit and quality improvement. It does not replace clinical judgement, local policy, specialist advice or urgent escalation pathways.
• This is not a preoperative test-ordering algorithm, not an anaesthetic risk calculator, not a consent tool and not a prescribing tool. No medication stop or start rules are imposed.
• Urgent or emergency surgery should not be delayed inappropriately by the audit process. Clinical urgency, anaesthetic and surgical judgement and senior decision-making take priority.
• Local preoperative assessment, anaesthesia, day surgery, anticoagulation, diabetes, VTE, blood management, infection prevention, pregnancy testing, consent, capacity, safeguarding, frailty and escalation policies apply.
• Use anonymous case identifiers only — never patient-identifiable information.

Supporting guidance from the Lazomis QI Resource Library. Authoritative clinical standards referenced by this project remain separate.

• Clinical GovernanceIntegrating Quality Improvement into Clinical Governance FrameworksThis article explores the vital relationship between Quality Improvement (QI) and Clinical Governance within the NHS, demonstrating how they are two sides of the same coin when aiming for continuous, systematic improvement in patient care.
• Quality ImprovementHow Many PDSA Cycles Does a Quality Improvement Project Need?This guide explains the iterative nature of PDSA cycles and offers practical advice for determining the appropriate number of cycles needed for effective quality improvement in NHS settings.
• Quality ImprovementPlanning Effective PDSA Cycles for Quality ImprovementThis guide provides a practical, step-by-step approach to planning effective Plan-Do-Study-Act (PDSA) cycles for quality improvement initiatives within the NHS, focusing on robust design and learning. It covers essential considerations from defining your aim to anticipating challenges, helping teams systematically test changes.
• Clinical GovernanceEffective Clinical Governance Meetings: Driving Improvement, Not Just ReportingThis guide helps NHS teams redefine their clinical governance meetings, moving beyond mere reporting to foster proactive discussion, shared learning, and tangible improvement actions for patient safety and quality of care.