Preoperative History and Physical (H&P) Template Climov - November 25

Name

[Enter patient name.]

DOB

[Enter patient date of birth.]

MRN

[Enter patient medical record number.]

Chief Complaint

Preoperative History and Physical (H&P) Template

Main concerns

[Document the patient's main concerns related to the planned surgery.]

No changes in medical issues

[Indicate if there are no changes in the patient's medical issues. If there are changes, document them here.]

Allergies

[List any known allergies or state 'No known allergies' if applicable.]

Medications

[List all current medications, including name, dosage, and frequency. If none, state 'No current medications.']

Past Medical History

[Document the patient's past medical history, including any chronic conditions or significant illnesses.]

Past Surgical History

[Document the patient's past surgical history, including dates and types of surgeries if available.]

Social History

[Document relevant social history, including lifestyle factors such as occupation, living situation, and habits.]

Smoking History

[Document the patient's smoking history, including current or past use, duration, and quantity. If non-smoker, state 'Non-smoker.']

Preop H&P

[This section serves as the header for the preoperative history and physical examination.]

General

[Describe the patient's general appearance, including nutritional status, age appearance, and any acute distress.]

Head and Neck

[Document findings related to the head and neck, including any history of surgeries/scars, Mallampati score, 3-3-2 rule, obstruction/trauma, and neck mobility.]

Skin

[Describe the skin's condition, including Fitzpatrick type, pigmentation, laxity, sagging, elasticity, fine lines, and wrinkles.]

Adiposity

[Document findings related to adiposity, particularly in the submental region and jawline.]

Submandibular Glands

[Describe the condition of the submandibular glands, including size, tenderness, and mobility.]

Jawline

[Document findings related to the jawline, including jowling and mandibular border definition.]

Respiratory

[Document respiratory findings, including effort and oxygenation status.]

Abdomen

[Document abdominal findings, including tenderness, distension, hernias, and any surgical scars or incisions.]

Extremities

[Document findings related to the extremities, including clubbing, cyanosis, or edema.]

Neurologic

[Document neurologic findings, including orientation, cranial nerve function, and any focal deficits.]

Chaperone

[Document the presence of a chaperone during the examination, including their name and confirmation that the examination was professional and appropriate.]

Assessment

[Summarize the patient's condition, including age, relevant medical history, and the reason for the planned surgery. Include any specific findings or considerations.]

Assessment

[Summarize the patient's condition, including age, relevant medical history, and the reason for the planned surgery. Include any specific findings or considerations.]

Plan

[Outline the plan for the patient, including the following:] - [Confirm proceeding with surgery as planned.] - [Document ASA classification, Mallampati score, 3-3-2 rule, neck mobility, allergies, and lab review.] - [Note any medications the patient is taking or has stopped.] - [Describe any markings made for surgery.] - [Confirm that consents and potential complications were reviewed with the patient.]

Planned surgery today

[Specify the planned surgery for today.]

Anesthesia

[Specify the type of anesthesia planned, e.g., IV sedation.]

Plan

[Outline the plan for the patient, including the following:] - [Confirm proceeding with surgery as planned.] - [Document ASA classification, Mallampati score, 3-3-2 rule, neck mobility, allergies, and lab review.] - [Note any medications the patient is taking or has stopped.] - [Describe any markings made for surgery.] - [Confirm that consents and potential complications were reviewed with the patient.]

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