Preoperative Form
The preoperative form captures all pre-anaesthesia assessment data. It is the first step in every case.
Patient demographics
Enter the patient's:
- Age (years)
- Sex (Male / Female / Other)
- Height (cm) and Weight (kg) — BMI is calculated automatically
- Blood type and Rh factor (optional)
IBW (Ideal Body Weight) and ABW (Adjusted Body Weight) are calculated automatically from height, weight, and sex. These are important for drug dosing in obese patients.
Case details
- Diagnosis — search by ICD-11 code or free text. The ICD-11 WHO classification is available in English and Bulgarian.
- Planned procedure — the surgical procedure to be performed
- Surgeon name, Anaesthesiologist name, Anaesthesia nurse name
Comorbidities
Select active comorbidities from the ICD-10 list. Multiple comorbidities can be added. They appear as chips that are displayed on the printed protocol.
Safety fields
- Allergies — tick if the patient has known allergies, then describe them in the text field
- Latex allergy — separate checkbox due to its anaesthetic relevance
- Current medications — free text
- Family anaesthesia problems — tick if there is a family history of malignant hyperthermia or other relevant conditions
Airway assessment
The airway section covers all standard pre-anaesthesia airway evaluation parameters:
| Field | Description |
|---|---|
| Mallampati class | I–IV, selected visually |
| Mouth opening (inter-incisor distance) | in cm |
| Thyromental distance | in cm |
| Neck mobility | Full / Limited / Fixed |
| Upper lip bite test (ULBT) | Class I / II / III |
| Cormack–Lehane grade | I / IIa / IIb / III / IV |
| Difficult airway history | Flag + free text for details |
Preoperative vitals
Record the patient's vital signs at the time of assessment:
- Blood pressure (systolic / diastolic, mmHg)
- Heart rate (bpm)
- SpO₂ (%)
- Temperature (°C)
- Respiratory rate (/min)
- ECG rhythm
Risk scores
ASA classification (required) — I through VI, with an emergency modifier (ASA-E).
The following scores are calculated automatically as you fill in the relevant sections of the form:
| Score | What it predicts |
|---|---|
| RCRI (0–6) | Major adverse cardiac events |
| Apfel (0–4) | Postoperative nausea and vomiting (PONV) |
| STOP-BANG (0–8) | Obstructive sleep apnoea risk |
Laboratory results
Add individual lab results (Hb, Hct, PLT, INR, creatinine, electrolytes, glucose, etc.) with value and unit. These appear in the printed protocol.
Premedication
Record evening and morning premedication if prescribed.
Saving
The preoperative form auto-saves as you type. When all mandatory fields are complete, click Save & continue to move to the intraoperative form. Mandatory fields are: age, sex, height, weight, diagnosis, planned procedure, and ASA score.