FMLH Preoperative Guidelines for Off-Campus Providers
Preoperative H+P Template
PREOPERATIVE HISTORY AND PHYSICAL
CHIEF COMPLAINT:
HISTORY:
This is a _____-year-old who complains of ____________(as dictated). ____(He/She) now
presents for ________(procedure). Dr. ______ (Surgeon) has requested that I provide
preoperative consultation before this procedure.
PAST MEDICAL HISTORY:
1.
2.
3. etc
(physician mentions if old/outside records were reviewed)
PAST SURGICAL HISTORY:
1.
2.
3. etc
Patient (denies/complains of) previous surgical or anesthetic complications.
MEDICATIONS:
1.
2.
3. etc
ALLERGIES:
1.
2. etc
SOCIAL HISTORY:
(married/single) (Smoker/non-smoker)(drugs/no drugs) (alcohol use)
FAMILY HISTORY:
REVIEW OF SYSTEMS:
HEENT:
Constitutional:
Cardiovascular:
Respiratory:
Gastrointestinal:
Genitourinary:
Musculoskeletal:
Skin:
Updated May 2012
Slawski
FMLH Preoperative Guidelines for Off-Campus Providers
Preoperative H+P Template
Neuro:
Psych:
Endocrine:
Heme/Lymph:
Allergic/Immune: (
FUNCTIONAL CAPACITY: (less than 4 METS) OR (greater than 4 METS). Explain justification for
functional capacity (i.e. can run two miles)
PHYSICAL EXAM:
GENERAL:
VITAL SIGNS: P ___, BP___, R____, wt___, ht____, pulse ox ____
SKIN:
HEENT: Note Mallampati class (I,II,III, or IV) airway
NECK:
LYMPH:
LUNGS:
CARDIOVASCULAR:
ABDOMEN:
MUSCULOSKELETAL:
PSYCH:
NEUROLOGIC:
DIAGNOSTIC STUDIES:
ASSESSMENT AND PLAN:
1. CARDIAC EVALUATION:
A. Ischemic Cardiac Risk.
B. Ventricular function.
C. Valvular heart disease.
D. Arrhythmias.
E. Beta blockade. Patient (does/does not) meet criteria for beta blockade.
F. Hypertension
2. PULMONARY EVALUATION:
3. HEMATOLOGIC EVALUATION
A. Bleeding Risk.
B. VTE Prophylaxis/Thrombotic risk and recommendations.:
4. ENDOCRINE EVALUATION (only if dictated):
A. Diabetes mellitus.
B. Adrenal insufficiency risk.
5. MEDICATION Instructions
6. . (other) (Additional medical problems addressed)
Updated May 2012
Slawski