Foot/Ankle Surgery Preoperative H&P

Patient Name: [Patient name]

MRN: [MRN]

DOB: [DOB]

Date/Time: [Date and time of note]

Author: [Clinician name and credentials]

Encounter Type: Preoperative H&P — [Initial Comprehensive H&P / Interval Update to Prior H&P dated [date] / Focused Assessment]

Planned Surgery Date: [Date]

Setting: [ASC / HOPD / Inpatient]

PCP: [Name or practice]

Relevant Consultants: [Names and specialties] (Include only if involved in perioperative care.)

Surgical Snapshot

• Planned Procedure(s): [Full procedure name(s)] (Use exact procedure names; avoid abbreviations alone.)
• Laterality and Operative Site: [Explicit laterality and specific site] (Must be explicitly documented; never infer from imaging or diagnosis.)
• Preoperative Diagnoses: [Primary diagnosis and relevant secondary diagnoses]
• Indication Category: [elective degenerative / deformity / instability / trauma / infection / ulcer-limb salvage / hardware complication]
• Anticipated Anesthesia: [general / regional / MAC / TBD per anesthesia]
• Anticipated Implants/Biologics: [Plates/screws, arthroplasty system, allograft, bone substitute, none, or N/A]
• Expected Post-Op Weight-Bearing: [NWB / TTWB / PWB / WBAT] with [immobilization type] for [estimated duration]
• High-Risk Factors: [List applicable: diabetes/neuropathy, PAD, active smoking/nicotine, chronic anticoagulation, OSA, prior VTE, immunosuppression, prior infection/nonunion, or none identified]

Chief Complaint

[Chief complaint in one concise line] (For interval updates referencing an unchanged prior H&P, this may be omitted.)

History of Present Illness

[Summary of diagnosis, laterality, chronicity, and reason for surgery now]

[Symptom characterization including pain location/severity/timing/triggers, instability or giving way, locking/catching, deformity progression, swelling, neurologic symptoms, and infection-related symptoms when relevant]

[Functional impact including walking tolerance, stairs, work restrictions, ADL impact, assistive device use, shoe-wear limitations]

[Pertinent chronology including prior injuries, surgeries, injections, wound episodes, hardware]

[Patient goals and shared decision context]

(For trauma or infection cases, emphasize mechanism, timing, wound status, neurovascular changes, and time-critical considerations. If history is limited, document why and source used.)

Failed Conservative Management

• [Modalities tried with approximate dates/duration and patient response] (Activity modification, footwear changes, orthotics/bracing, immobilization, NSAIDs/analgesics, physical therapy, injections, offloading, wound care, antibiotics, work modifications. Note adherence or constraints.)
• Objective failure statement: [Why nonoperative care was insufficient]

(If conservative care is not appropriate—acute trauma, infection requiring source control, threatened soft tissue, progressive neurologic compromise—document why delay is unsafe or unlikely to succeed.)

Pertinent Diagnostic Data Reviewed

• Imaging: [Study type, date, and key findings supporting diagnosis/necessity] (If external imaging exists but unavailable, note "requested/not available for review.")
• Labs: [Relevant values—A1c, renal function, inflammatory markers, vitamin D, cultures] (Include only if pertinent to risk and planning.)

Past Medical History

[Problem list focused on perioperative risk: diabetes with control status, neuropathy, PAD, CKD, CAD/CHF, COPD/asthma, OSA with CPAP use, prior stroke, clotting disorders, rheumatoid/inflammatory disease, immunosuppression, obesity, osteoporosis]

Past Surgical History

• [Prior foot/ankle surgeries with side, existing hardware, wound complications]
• [Other major surgeries relevant to anesthesia or perioperative risk]
• Anesthesia history: [PONV, difficult airway, malignant hyperthermia, awareness, severe reactions, or no known complications]

Bleeding and Clotting History

[Prior DVT/PE; family history of clotting or bleeding disorders; personal bleeding disorders or abnormal bruising; transfusion history] (Document "unknown" if relevant and not available.)

Medications and Perioperative Plan

[Current medication list with name, dose, route, frequency; include last dose timing for high-risk medications when known]

• Anticoagulants/Antiplatelets: [Agent, indication, prescriber, hold/bridge plan, restart plan] (If deferred, document who will decide, that guidance was requested, and interim patient instructions.)
• Diabetes Medications: [Insulin adjustments; oral/GLP-1/SGLT2 hold/continue plan] (SGLT2 typically held 3–4 days pre-op; GLP-1 per anesthesia guidance.)
• Steroids/Immunosuppressants: [Continue/hold plan; stress dosing if indicated]
• NSAIDs: [Stop timing if applicable]
• Chronic Opioids: [Baseline regimen, tolerance considerations, perioperative approach]
• Herbals/Supplements: [List with stop timing, or none] (Explicitly ask and document.)

Allergies

[Allergen — reaction type and severity] (Highlight antibiotic allergies, latex, chlorhexidine/iodine sensitivity. If reaction unknown, state so and note risk mitigation.)

Review of Systems

• Constitutional: [Fever/chills, weight loss, pertinent positives/negatives]
• Cardiopulmonary: [Chest pain, shortness of breath, orthopnea, exertional tolerance]
• Hematologic: [Easy bruising/bleeding]
• Endocrine: [Diabetes symptoms, hypoglycemia history]
• Skin/Wound: [Ulcers, rashes near surgical site]
• Neurologic: [Neuropathy symptoms, focal deficits]
• Pregnancy status: [Document per local workflow when applicable]

Social History

• Tobacco/Nicotine: [Type, quantity, current status, quit date, cessation plan]
• Alcohol: [Quantity/pattern; withdrawal risk if relevant]
• Substances: [Type/frequency; implications for anesthesia/pain plan]
• Home Situation and Support: [Stairs, caregiver availability, ability to comply with non-weight-bearing, transportation]
• Work/Functional Demands: [Occupation, restrictions, anticipated return-to-work]

Preoperative Risk Assessment and Optimization

• Functional Capacity: [Activity tolerance; note if limited by foot/ankle pain versus cardiopulmonary symptoms]
• Cardiovascular: [Known disease/devices, current symptoms; need for testing/clearance and plan]
• Pulmonary/OSA: [Diagnosis, CPAP use, symptom control; perioperative plan]
• VTE Risk: [Patient-specific and procedure-specific factors including immobilization/NWB duration; overall risk assessment]
• Infection/SSI Risk: [Diabetes control, smoking status, skin integrity, prior infections; pre-op skin prep instructions; MRSA screening/decolonization if indicated]
• Vascular Status: [Pulses, PAD history, wound healing history; ABI/TBI or vascular consult if indicated]
• Bone Healing Risk: [Vitamin D deficiency, osteoporosis, smoking, NSAID use, prior nonunion]
• Optimization Plan: [What is optimized, what is pending, requirements before proceeding] (Do not state "cleared" unless formal clearance exists.)

Physical Examination

Vitals: [BP, HR, RR, Temp, SpO2, BMI]

General: [Appearance, cooperation, distress] | Cardiopulmonary: [Focused heart and lung exam] | Skin: [Notable findings]

Focused Foot/Ankle Exam (Operative Side)

• Inspection: [Swelling, erythema, deformity, ecchymosis, scars, ulcers, callus, drainage]
• Palpation: [Tenderness localization, warmth]
• Range of Motion: [Ankle/subtalar/midfoot/1st MTP as relevant; pain with motion]
• Stability Testing: [Anterior drawer, talar tilt, syndesmotic testing as relevant]
• Neurovascular: [Sensation distribution with neuropathy documented; motor strength; DP/PT pulses; capillary refill; skin temperature; edema]
• Gait/Weight-Bearing: [Tolerance if assessed]

(If exam limited by splint/cast/dressing, document what could not be assessed, why, and what was assessed. Include contralateral comparison if it supports medical necessity.)

Assessment

[Synthesis linking symptoms, objective findings, diagnostic data, and failed conservative care to the surgical indication]

• Primary Surgical Problem: [Diagnosis with laterality]
• Key Comorbidities Affecting Risk: [List]
• Other Active Issues Requiring Perioperative Action: [List]

Plan

Operative Plan: [Planned procedure(s) and laterality; approach/technique; anticipated implants/biologics; expected disposition and LOS if inpatient]

Medical Necessity Statement: [Connect diagnosis, functional limitations, objective findings, nonoperative management attempted and failed or why not appropriate, and why proposed surgery is expected to address the problem]

Perioperative Medications: [Antibiotic prophylaxis agent with allergy alternative; anticoagulant/antiplatelet hold-bridge-resume plan; diabetes medication perioperative plan]

VTE Prophylaxis: [Mechanical prophylaxis; chemical prophylaxis agent/duration/start time if indicated with rationale; if no chemoprophylaxis, document rationale]

Post-Op Weight-Bearing and Wound Care: [Immobilization device and timeline; wound care instructions; return precautions]

Pain Management: [Multimodal plan including acetaminophen, NSAID if allowed, regional anesthesia, neuropathic agents; opioid plan with expected duration; coordination for chronic opioid patients]

DME and Rehabilitation: [Assistive devices; PT timing; home health needs; work restrictions]

Follow-Up: [Post-op visit timing; contingency plans if intraoperative findings differ]

Informed Consent Discussion

[Document discussion of diagnosis and rationale; alternatives including continued nonoperative care; material risks including infection, wound complications, nonunion, malunion, hardware failure, neurovascular injury, DVT/PE, persistent pain/stiffness, need for revision, anesthesia risks; questions addressed; patient elected to proceed. Note consent form status per facility workflow.]

Patient Instructions

• [NPO instructions]
• [Skin prep regimen]
• [Medication instructions for day of surgery]
• [Smoking cessation instructions if applicable]
• [Logistics: driver, caregiver, assistive device acquisition]

(If instructions deferred to PAT/anesthesia, document that patient was advised not to independently stop anticoagulants or diabetes medications without directed guidance.)

Interval Update

(Complete per facility policy before anesthesia when H&P was completed days–weeks before surgery.)

• Patient examined today: [No changes since H&P dated [date] / changes as follows: [list]]
• Allergies: [Unchanged / updated]
• Medications: [No changes / changes since prior H&P, especially anticoagulants/diabetes agents]
• New Infections: [None / details]
• New Cardiopulmonary Symptoms: [None / details]
• Pregnancy Status: [Confirmed status when applicable]

(This update must reflect an interval examination, not clerical restatement.)