As an early trainee, your responsibility is to conduct a thorough and exhaustive chart review. The ultimate goal is to be the person in the room who knows the most about the patient. In your workflow as a trainee, you are typically served one case at a time, usually with plenty of lead time. There is no excuse to skim the chart or miss key details.

When unexpected complications arise, it’s often the well-prepared trainee or student who recalls a crucial piece of the patient’s history that no one else noticed. In this scenario, you are not only providing valuable patient care but also showing that you can contribute meaningfully to patient safety and team performance.

Working alongside surgeons, it can be tempting to mirror their approach to chart review: reducing patients to a bare minimum of technical facts and relying on perioperative medical consultants to fill in the gaps. But if you’ve read Chapter 8, you know that your role is to be that perioperative medical consultant. When a crisis unfolds, you are the final line of defense. Don’t be caught unprepared!

As an attending supervising multiple rooms, I find it extremely valuable when a trainee has a full roster of information on the patient. Similarly, I find it frustrating if the trainee has skimped on history, and I find myself having to tell them about the patient.

Over time, you will learn to sort information into three buckets:

1. Critical information: These are details that must be known even in the most urgent situations. They include allergies, code status, and gastrointestinal considerations such as recent vomiting, obstruction, ileus, or upper GI symptoms. These directly influence immediate anesthetic decisions and safety.
   
2. History that informs the anesthetic plan: This information is necessary to plan and safely execute the anesthetic. These include cardiopulmonary history (including relevant cardiac studies), recent CBC, creatinine, coagulation profile, airway assessment, prior airway or IV access challenges, and any anesthetic complications. These details help anticipate problems and tailor the anesthetic accordingly.
   
3. Background information: These are useful to know, but typically don’t need to be part of a formal presentation. Examples include remote chemotherapy, stable chronic conditions like hypothyroidism or asthma, and psychiatric history. While they may not impact the anesthetic plan directly, they add context to the overall clinical picture.

As your experience grows, you’ll learn to titrate how much information you gather and present based on the type of case and its urgency. A trauma patient may have little in the way of history, but critical information is still necessary, such as an airway exam and relevant imaging.

As a trainee, you should err on the side of over-informing yourself. Short of a truly emergent situation like a level 1 trauma or a ruptured aortic aneurysm, there is no excuse to skimp on a pre-op. Preparation also helps to significantly reduce your stress level as a trainee. The information is your safety net.

Where to start? In my experience, the best starting point is the history and physical (H+P) completed by the proceduralist or the patient’s most recent clinic visit. While it may miss a great deal of relevant anesthetic information, it provides context for the case. From there, expand your review to include relevant specialty notes such as those from primary care, cardiology, pulmonology, etc.

Your next step is to review cardiac studies (EKG, echocardiogram) and imaging. Make a habit to review the EKG and echocardiogram findings yourself, rather than simply reading the summary of the interpretation. There is more to an echocardiogram than just the ejection fraction: valvular function, end-diastolic diameter, estimated pulmonary artery pressures, presence of effusions, and the grade of diastolic dysfunction. These details might not matter every day, but they’ll build your clinical intuition over time, especially in complex or critically ill patients.

The majority of cross-sectional imaging studies (CT, MRI) won’t materially alter your anesthetic plan, but learning how to interpret them will help you develop pattern recognition. You’ll start to distinguish between common, benign findings and those that warrant deeper investigation. Abnormal CT findings will help keep you curious and informed.

The next place to look is recent labs. You don’t need to report every abnormal lab to your attending, but you should flag any result that could impact your anesthetic plan. Learning which labs matter (and when) is a key part of your growth. Labs that will impact the surgical and anesthetic plan include recent coagulation studies, the most recent hemoglobin, and creatinine.

A patient’s home medications offer important insight into chronic conditions that may not be clearly documented elsewhere in the chart. Chronic use of opioids, stimulants, or anxiolytics is important for formulating a postoperative pain control plan.

Reviewing previous anesthetics is critical, especially for any documentation on airway management challenges, difficult IV access, or notable intraoperative events. Even if the number of records is high, it’s generally a good idea to review at least key events and notable intraoperative anesthetic notes. This may feel trivial to you, but seeing that you have access to previous anesthetic experiences is very important to the patient.

For patients on chronic opioids, rather than saying they are “opioid tolerant,” you should be more granular. You can estimate their morphine milligram equivalents (MMEs) to establish a rough sense of their baseline opioid needs. Online opioid conversion tools can help, typically incorporating a 25–50% reduction to account for incomplete cross-tolerance. These tools are not exact, but they provide a useful frame of reference. The goal is to meet, at a minimum, the patient’s baseline opioid requirement to prevent withdrawal and manage pain effectively.

In addition to the above, for hospitalized patients, you should have an up-to-date understanding of their current active medical issues. This should include vital signs, lines and drains, lab results, NPO status, and the presence of an active type and screen. You should also review when their last dose of pharmacologic DVT prophylaxis was given.

Care fragmentation is common in hospitalized patients, and anesthesiologists are often left to tie the loose ends of perioperative care. It’s no exaggeration: an attentive, thorough preoperative assessment can change the course of care and, in some cases, save a life. Below are some examples from my own experience (with details slightly changed for anonymity) where a trainee’s pre-op made a critical difference:

• Avoided iatrogenic injury: A trainee caught that a patient with a prior bladder resection excreted urine via ureterostomy tubes. Their note prevented the surgical team from inadvertently placing a Foley catheter into a blind pouch.
  
• Prompted life–saving delay: A resident flagged new arm pain and dizziness in an inpatient scheduled for cervical laminectomy. Further workup revealed an NSTEMI, prompting cardiac optimization and delaying the surgery appropriately.
  
• Caught a retained foreign body: After a port placement, a trainee followed up on the postoperative chest X-ray and identified a retained foreign object, allowing timely intervention.
  
• Prevented a surgical complication: Prior to a below-the-knee amputation, a trainee noted a tibial rod in the leg. The case was postponed so orthopedics could be involved, ensuring proper equipment and planning.
  
• Avoided hemorrhagic disaster: During a pre-op interview, a trainee uncovered a recent episode of hemoptysis. The planned procedure involved large-dose IV heparin, which would have been catastrophic. Further workup revealed a bleeding gastric ulcer.
  
• Optimized line placement: A trainee read the operative note from a recent CABG, noting that the right radial artery had been harvested. This prevented the team from making futile attempts at right radial arterial cannulation.
  
• Informed vascular access strategy: A detailed pre-op uncovered thoracic outlet syndrome, which directly influenced the choice of arterial and central line sites, improving patient safety and procedural ease.