Form 4023 PDF Details

Undergoing surgery, whether minor or major, demands comprehensive preparation to ensure patient safety and the best outcomes. The 4023 form plays a crucial role in this process, serving as a standardized document for preoperative medical evaluation and clearance. It requires completion by a healthcare professional, who assesses the patient's medical history, current health status, and the specific demands of the surgery being considered. Details such as the patient's age, sex, proposed surgical procedure, medical problems, allergies, and prior surgeries are meticulously recorded. Additionally, the form prompts for a thorough physical examination, encompassing various health aspects from blood pressure and heart rate to more detailed investigations like the HEENT (head, eyes, ears, nose, and throat) assessment. Pertinent diagnostic data, guided by attached American Society of Anesthesiologists (ASA) recommendations, are also documented, including preoperative tests and results. Finally, the form includes sections for recommendations on patient readiness for surgery, any reasons for potential delay, further recommendations, and specific pre-surgery instructions. By rigorously outlining these elements, form 4023 ensures that patients are thoroughly evaluated, minimizing risks and optimizing conditions for successful surgical outcomes.

QuestionAnswer
Form Name Form 4023
Form Length 3 pages
Fillable? No
Fillable fields 0
Avg. time to fill out 45 sec
Other names printable pre op clearance form, pre op clearance form pdf, pre op surgery forms, surgical clearance form, baptis hospital of miami form 4023

Form Preview Example

PREOPERATIVE MEDICAL EVALUATION

AND CLEARANCE FOR SURGERY

Fax to (786) 596-3676

Baptist Pre-Surgery Office

Date of Examination___________________

Must be completed: G 3 Days G 7 Days (MAJOR SURGERY)

before surgery

Patient Name _________________________________________________ Age________ Sex ________

Date of Surgery__________________ Location of Surgery Baptist Hospital

Physician _________________________________ Surgeon __________________________________

Specialist _________________________________ Specialist _________________________________

Proposed Surgical Procedure ____________________________________________________________

Indication for Surgery __________________________________________________________________

Medical Problems

GNone

1._______________________________________________________________________________

2._______________________________________________________________________________

3._______________________________________________________________________________

4._______________________________________________________________________________

5._______________________________________________________________________________

Cigarettes ___________________________________________ Alcohol ________________________

Medications _________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

Allergies G None ____________________________________________________________________

Prior Surgery G None ________________________________________________________________

____________________________________________________________________________________

Previous Surgical Complications G None

__________________________________________________

History of Excessive Bleeding

G None

G Patient

G Family

Physical Exam:

 

 

 

BP _____________ HR ____________

Ht ____________

Wt ____________ LMP ___________

HEENT _____________________________________________________________________________

Neck _______________________________________________________________________________

Chest and Lungs _____________________________________________________________________

Heart _______________________________________________________________________________

Abdomen ___________________________________________________________________________

Extremities __________________________________________________________________________

Neuro/ Mental Status __________________________________________________________________

Other Pertinent Findings:________________________________________________________________



*09200B4023*

Page 1 of 2 ! Form #4023 (Rev. 12/08)

PREOPERATIVE MEDICAL EVALUATION

AND CLEARANCE FOR SURGERY

Pertinent Diagnostic Data: See attached ASA Recommendations

Not Indicated Preop Tests

Date

Results

G

EKG

____________

_________________________________________

G

CXR

____________

_________________________________________

G

U/A

____________

_________________________________________

G

CBC

____________

_________________________________________

G

Chemistry

____________

_________________________________________

G

PT/PTT

____________

_________________________________________

G

Cardiac Echo

____________

_________________________________________

G

Stress/Cath

____________

_________________________________________

G

HgbAlC (Diabetic patients) ____________

_________________________________________

G

SCrCl (PCN allergy)

____________

_________________________________________

Other

___________

____________

_________________________________________

Recommendations:

GThe patient is not in optimal medical condition for the proposed surgery for the following reason(s):

_________________________________________________________________________________

_________________________________________________________________________________

GDelayed - Surgery should be delayed for the following reason(s):

_________________________________________________________________________________

_________________________________________________________________________________

GThe patient is in optimal medical condition to undergo surgery at this time

Further Recommendations: ___________________________________________________________

_________________________________________________________________________________

Instructions to patients: _________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

 

Signature__________________________________________________

 

MD Name _________________________________________________



Specialty_________________________________ Date ____________

 

*09200B4023*

Page 2 of 2 ! Form #4023 (Rev. 12/08)

How to Edit Form 4023 Online for Free

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Step 1: First of all, open the editor by clicking the "Get Form Button" in the top section of this webpage.

Step 2: After you launch the editor, you'll see the document prepared to be completed. Besides filling out various blanks, you might also do other sorts of things with the form, particularly putting on your own text, modifying the original textual content, adding illustrations or photos, placing your signature to the form, and more.

This form will require you to type in some specific information; to guarantee accuracy and reliability, you need to take note of the guidelines just below:

1. You need to complete the surgery clearance form properly, therefore be attentive while filling out the parts comprising these blanks:

pre op surgery forms completion process clarified (part 1)

2. After this section is done, you have to insert the required details in Medications, Allergies G None Prior Surgery G, BP HR Ht Wt LMP, HEENT, Neck, Chest and Lungs, Heart, Abdomen, Extremities, Neuro Mental Status, and Other Pertinent Findings allowing you to move on further.

Guidelines on how to fill in pre op surgery forms part 2

3. The next stage is normally hassle-free - fill in all the empty fields in G G G G G G G G G G, EKG, CXR, CBC, Chemistry, PTPTT, Cardiac Echo, StressCath, HgbAlC Diabetic patients, SCrCl PCN allergy, Other, Recommendations G The patient is, and G Delayed Surgery should be in order to finish this segment.

Part no. 3 of completing pre op surgery forms

4. This particular paragraph comes with these particular empty form fields to fill out: G Delayed Surgery should be, G The patient is in optimal, Instructions to patients, Signature, MD Name, and Specialty Date.

Stage no. 4 for submitting pre op surgery forms

It is easy to make an error while filling in the Specialty Date, for that reason ensure that you go through it again before you'll finalize the form.

Step 3: Look through what you've inserted in the blanks and press the "Done" button. Right after getting afree trial account with us, you will be able to download surgery clearance form or email it immediately. The PDF file will also be accessible in your personal cabinet with all of your changes. When using FormsPal, you can easily fill out documents without needing to be concerned about data incidents or entries being distributed. Our protected software ensures that your private data is kept safe.