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

This ready-built project is developed using the guidance, standards and authoritative sources listed below, so you can see what is being measured and why. Lazomis QI does not publish or own this guidance, and inclusion here does not imply endorsement or approval by any of these organisations.

• NICE

  NG45: Routine preoperative tests for elective surgery(opens the original source in a new tab)

  National guidance on which preoperative tests are indicated for elective surgery by surgical grade, ASA grade and comorbidity.

• Centre for Perioperative Care

  Preoperative Assessment and Optimisation for Adult Surgery(opens the original source in a new tab)

  National guideline describing the content, timing and organisation of preoperative assessment and optimisation.

• NHS England

  Earlier screening, risk assessment and health optimisation in perioperative pathways(opens the original source in a new tab)

  National expectations for earlier risk assessment and optimisation within elective surgical pathways.

• Royal College of Anaesthetists

  GPAS Chapter 2: Guidelines for the Provision of Anaesthesia Services for the Perioperative Care of Elective and Urgent Care Patients(opens the original source in a new tab)

  Service standards for preoperative assessment, anaesthetic review and perioperative planning.

• Royal College of Anaesthetists

  GPAS Chapter 6: Guidelines for the Provision of Day Surgery Services(opens the original source in a new tab)

  Service standards for day surgery pre-assessment, selection and discharge planning where relevant.

• NICE

  CG138: Patient experience in adult NHS services(opens the original source in a new tab)

  Relevant where communication, information provision and involvement in decisions are assessed.

• NICE

  NG197: Shared decision making(opens the original source in a new tab)

  Relevant where shared decision-making discussions form part of preoperative assessment documentation.

• 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 GovernanceLeveraging Incident Themes for Quality Improvement and Patient SafetyThis guide helps NHS teams identify and analyse recurring incident themes, transforming reported safety events into practical quality improvement opportunities to enhance patient safety and system reliability.
• 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.
• Patient SafetyIntegrating Patient Safety and Quality Improvement: A Practical Guide for UK CliniciansThis guide explains the foundational principles of patient safety and quality improvement (QI) within the UK healthcare context, offering practical strategies for clinicians to enhance safety and improve care delivery.
• Patient SafetyHow to Select a Patient Safety Quality Improvement ProjectThis guide helps NHS teams identify and select patient safety quality improvement (QI) projects that are impactful, achievable, and aligned with organisational and national priorities. Learn how to move from identifying concerns to choosing a focused and measurable project.