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Pre op physical exam template

Preoperative history and physical form 2025

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The document is a Preoperative History & Physical Form for the WRHA Surgery Program, which must be submitted at least 14 days before a scheduled surgery. It includes sections for patient alerts, medical history, physical examination details, optimization strategies to reduce postoperative complications, and laboratory screening requirements. The form emphasizes the importance of accurate contact information and outlines necessary preoperative tests based on the type of surgery.

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What are the physical preparation of preoperative surgery?

A typical pre-operative regime is no food up to 6 hours before surgery, with clear fluids only up to 2 hours before surgery*. Fasting ensures that the stomach is empty of contents, in turn reduces the risk of aspiration, which can cause aspiration pneumonitis and / or aspiration pneumonia.

What is a pre-op history and physical?

Your preoperative exam will: Measure your height, weight and vital signs. Review your medication list, with recommendations for how to take your medications prior to surgery. Review your medical, surgical and family history. Include a physical exam.

What are the components of the focused history and physical exam?

In documenting a focused history and performing a focused physical examination, you need to explore the chief complaint, the history of the present illness, the past medical history, medications and allergies, the family history and social history, the occupational history, and the sexual history that are relevant to

What is included in a history and physical note?

The history component of an HP gathers relevant information about the patients history with their current chief complaint. This includes reviewing any pre-existing conditions, past hospitalizations and surgeries, allergies, medications being taken, and family medical history.

What is a preop HP?

Any patient scheduled for surgery or an invasive procedure must have a complete history and physical examination (H P) completed within 30 days of the procedure date. The H P must be dated, timed, and signed.

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What does a physical examination include?

A personal history may include information about allergies, illnesses, surgeries, immunizations, and results of physical exams, tests, and screenings. It may also include information about medicines taken and health habits, such as diet and exercise.

What is included in a patients history and Physical?

However, most reports start with identifying patient information, such as name, age, and gender. This is usually followed by a description of the chief complaint and a summary of the patients medical history. A review of the physical exams findings will follow, along with the physicians assessment and plan.