H&P Update (Day of Surgery)

Date/Time of Exam: [Date and time of today's exam]

Scheduled Procedure Date/Time: [Scheduled procedure date/time, if known]

Location: [Pre-op holding / Same-day surgery / Other]

Prior H&P Reference

• Date of Prior H&P: [Date]
• Author of Prior H&P: [Author name and role]
• Source/Setting: [Clinic note / Inpatient H&P / Other]
• Currency Statement: [Within 30 days—eligible for update / Older than 30 days—new H&P required / Prior H&P not located] (If older than 30 days, do not complete this update—perform a new H&P. If not located, document explicitly.)

Interval History

(Document only changes or new information since the prior H&P relevant to perioperative risk. Do not duplicate the original H&P.)

• Interim events: [No change / Summary of interim diagnoses, hospitalizations, ED visits, infections, procedures, or new symptoms]
• Medication changes: [No change / Summary of new, stopped, or dose-adjusted medications]
• Anticoagulant/antiplatelet status: [Not on therapy / Held—last dose: [date/time] / Active—last dose: [date/time] / Unknown—must confirm prior to proceeding] (Include if applicable. Use "Unknown—must confirm prior to proceeding" if information unavailable and regional/neuraxial anesthesia is planned.)
• New allergies or adverse reactions: [No change / New allergy with reaction type]
• Implants/devices relevant to surgery: [None / Device type and implications for electrocautery/positioning] (Include if applicable.)
• NPO status: [Last solids: [time]; Last clears: [time]] (Include only if explicitly mentioned; otherwise omit.)
• Pregnancy status: [Negative / Positive / Test pending] (Include only if applicable and explicitly mentioned; otherwise omit.)

Interval Physical Exam

(Focused to identify interval changes affecting perioperative risk.)

• Vital signs: [Values / See pre-op flowsheet] (Note any abnormalities in text.)
• General appearance: [Findings]
• Cardiovascular: [Rate/rhythm, murmurs, edema, hemodynamic stability]
• Respiratory: [Work of breathing, breath sounds, oxygen requirement]
• Procedure-specific exam:
  • Surgical site assessment: [Skin integrity, signs of infection, wounds/drains as applicable]
  • Site/Side/Level confirmation: [Confirmed with patient and consent / Not applicable]
  • Neurovascular status: [Intact / Deficits—describe] (Include for extremity procedures.)
• Comparison to prior H&P: [Exam unchanged from prior H&P / Interval changes identified—describe]

Interval Data Review

(Include only if there are new or pending results relevant to today's procedure; omit this section entirely if not applicable.)

• Pertinent labs: [Results with dates]
• Imaging relevant to procedure/site: [Summary of findings with dates]
• Consultations/clearances since prior H&P: [Obtained—summary / Pending—details]
• Pending results required to proceed: [None / Specify tests and contingency plan]

Procedure & Safety Verification

• Planned Procedure: [Exact scheduled/consented procedure name]
• Site/Side/Level: [Laterality/level when applicable]
• Indication: [Confirm necessity remains present]
• Consent Status: [Signed consent present in chart / Not verified / Consent not obtained] (Do not infer; document only what is explicitly verified.)
• Site Marking: [Required and completed / Required but not completed—reason / Not required per facility policy] (Do not infer; confirm per policy.)
• Discrepancies Identified: [None / Discrepancy and resolution plan]

Assessment and Plan

• Summary: [Brief summary of baseline condition and planned procedure]
• Interval changes: [None / Summary of changes and perioperative significance]
• Readiness statement: [Proceed as planned / Proceed with modifications—list / Postpone or cancel—reason and next steps]
• Perioperative plan elements: [Antibiotic prophylaxis, VTE prophylaxis, blood product plan, post-op disposition as applicable] (Include only if documentation required in this note; otherwise reference anesthesia or nursing records.)
• Pre-anesthesia evaluation: [Completed / Not documented] (Note any anesthesia-relevant findings identified today.)

Attestation

(Select one attestation based on findings.)

• "I have reviewed the prior H&P dated [date] and examined the patient today. There have been no interval changes in the patient's condition since that H&P."
• "I have reviewed the prior H&P dated [date] and examined the patient today. Interval changes are documented above and have been addressed in the updated plan."
• "Prior H&P reviewed but found to be incomplete/outdated for today's procedure; a new H&P has been completed."

Electronic Signature: [Provider name, credentials]

Date/Time: [Signature date/time]