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Pre-operative and pre-admission letter template

Australian documentation guide

A pre-operative or pre-admission letter body for documented information. It supports communication without supplying surgical clearance, an anaesthetic assessment or new medicine instructions.

The blank template

How to fill it in

  1. Copy the blank template into your record system.
  2. Fill in what was discussed or assessed. Keep uncertainty visible, and use [not stated] where required information is missing.
  3. Check the details and any gaps before saving or sharing. The clinician must explicitly confirm any generated content.

Procedure planned

Name the planned procedure and the source of that information. Include the site, side, clinician and date only when established. Keep proposed, booked and completed procedures distinct. A letter prepared before admission does not itself confirm a booking or consent for a procedure.

Relevant history

Summarise the history relevant to the planned care as documented by the clinician. Include the person’s concerns, communication needs and previous experiences when discussed. Identify information from earlier records and records still requested rather than making the summary sound like a new full assessment.

Current medications

Share the available medicine list, its date and how it was obtained. Keep precise directions and discrepancies visible. Include peri-operative instructions only if the responsible clinician explicitly documented them; do not create advice to stop, change or continue medicines from the procedure name.

Allergies and adverse reactions

Record the substance and reaction with the source and any uncertainty. Describe a previous anaesthetic reaction accurately without upgrading an account of nausea or another symptom into an allergy. If the required reaction history is missing, write [not stated].

Relevant investigations

List results actually available, with dates and any clinician interpretation that was stated. Distinguish an investigation requested from one completed, and a report mentioned from one enclosed. This section does not decide which tests should be ordered or infer fitness for a procedure from a result.

Anaesthetic considerations

Include relevant history or concerns actually documented, including the source and whether a current assessment has occurred. Preserve unanswered questions for the receiving team. Do not generate fasting instructions, an anaesthetic risk category or a statement of clearance to fill this section.

Common omissions

Look for unconfirmed procedure details, an unverified medicine list, missing reaction information and outstanding reports. Make any agreed follow-up owner visible. A request for pre-admission review and a completed review are different stages.

Review before sending

Check that the team can distinguish established information from work still pending. Verify identifiers, recipient, consent and enclosures in the sending system. Confirm any instructions against the responsible clinician’s record. This letter supports communication; any clearance or procedural assessment must be established through the actual clinical process.

Worked examples

A pre-admission summary with assessment still to occur

Fictional example. Made up for this guide; no patient record was used. It shows how to write a record, with gaps left visible. It is not a care plan or a record to copy into someone's chart.

PROCEDURE PLANNED: The surgeon's correspondence records a planned right cataract procedure. A procedure date is not yet confirmed in the available record. This summary is for the pre-admission team.
RELEVANT HISTORY: The person reports previous cataract surgery on the left. They say they would like written appointment instructions because they find phone conversations difficult to follow. The earlier operative record has been requested but not received.
CURRENT MEDICATIONS: The person reports daily vitamin D. Strength, dose and product details are not stated in this extract. No peri-operative medicine change is documented.
ALLERGIES & ADVERSE REACTIONS: The person reports a rash after amoxicillin in childhood; the original record is unavailable.
RELEVANT INVESTIGATIONS: No pre-operative investigation result is recorded in this fictional consultation. The letter does not establish whether testing is required.
ANAESTHETIC CONSIDERATIONS: The person reports nausea after an earlier anaesthetic; the date and anaesthetic details are not stated. No current anaesthetic assessment or clearance is recorded. The pre-admission appointment is requested but not yet booked.

An incomplete summary with no clearance established

Fictional example. Made up for this guide; no patient record was used. It shows how to write a record, with gaps left visible. It is not a care plan or a record to copy into someone's chart.

PROCEDURE PLANNED: A procedure is mentioned in earlier correspondence; its name, site, side and date are not stated in this extract.
RELEVANT HISTORY: [not stated]
CURRENT MEDICATIONS: [not stated]
ALLERGIES & ADVERSE REACTIONS: [not stated]
RELEVANT INVESTIGATIONS: Reports are described as requested; receipt and results are not confirmed.
ANAESTHETIC CONSIDERATIONS: [not stated]

Related templates

Start a consult with this template, free

Approved for publication by Tyson, 4 October 2026

Sources

Free to copy and adapt this template and guide, including for use in your practice. Sources linked above retain their own terms.

Use this guide to help write the record. It provides no clinical advice. The clinician remains responsible for checking that the record is accurate and complete. Check Medicare requirements, statutory forms and local policies separately.