Preoperative History & Physical Examination Form at a glance
What it is: Preoperative History & Physical Examination Form of Sinai Hospital, Rubin Institute for Advanced Orthopedics/International Center for Limb Lengthening.
Where and when to file: FAX COMPLETED FORMS ASAP: Patients of Dr. Herzenberg, Dr. Standard, Dr. Siddiqui, and Dr. Bibbo: 410-601-9575 Patients of Dr. Conway: 410-601-9576
A filled-in Preoperative History & Physical Examination Form example: a clinician completes the form before knee surgery
How to fill out Preoperative History & Physical Examination Form, box by box
Patient Name, Date, Date of Birth and Diagnosis
Enter the Patient Name, Date, Date of Birth and Diagnosis.
Proposed Surgical Procedure, Surgeon, Date of Surgery and PAST MEDICAL HISTORY
Enter the Proposed Surgical Procedure, the Surgeon, the Date of Surgery and the PAST MEDICAL HISTORY.
CURRENT MEDICATIONS and ALLERGIES
Under CURRENT MEDICATIONS, enter the Medication, Dosage and Frequency, and enter the ALLERGIES.
PAST SURGICAL HISTORY
Under PAST SURGICAL HISTORY, enter the Date, Surgery, Hospital Name and Complications.
SOCIAL HISTORY
Under SOCIAL HISTORY, enter Smoking, Alcohol and Caffeine.
REVIEW OF SYSTEMS - Check Box if Applicable
Under REVIEW OF SYSTEMS - Check Box if Applicable, check each box that applies, or None, and write any Comment on positives or symptoms not listed.
Page 2 Patient Name and Date of Birth
On page 2, enter the Patient Name and Date of Birth.
PHYSICAL EXAM
Under PHYSICAL EXAM, enter Sex, Race, Age, Height, Weight (KG), BP, Pulse, Resp and Temp.
General appearance and what is Abnormal
Enter the General appearance. Check each box that applies, from No Lymphadenopathy, No JVD and RRR S1S2, S3 and S4 to No Clubbing, No Cyanosis, No Edema and CN II-XII intact, and write what is Abnormal. Enter the ASSESSMENT. Mark the surgery proposed for this patient as low / intermediate / high risk.
The patient risk and PLAN
Mark the patient as representing low / intermediate / high risk of cardiac mortality because of minor / intermediate / major clinical predictors. Under PLAN, check either Further testing for this patient IS NOT recommended (the patient may proceed directly to surgery) or Further testing IS recommended for this patient, not both.
If you check Further testing IS recommended for this patient, list the test(s) to be obtained prior to the planned surgical procedure.
SIGN
Enter the MD/PA/NP Name (PRINT), Date and Phone Number, and sign on the Provider Signature line.
Sources
[1] Preoperative History & Physical Examination Form (PRE-OP H&P EXAM FORM REVISED 07-06-16), Sinai Hospital, Rubin Institute for Advanced Orthopedics/International Center for Limb Lengthening (the Official source link on this page).