Preoperative Evaluation Note (OMS Procedure)

Note Type: Preoperative Evaluation Note (OMS Procedure)

Date/Time: [Date and time of encounter]

Patient Name: [Full name]

DOB: [Date of birth]

MRN: [Medical record number]

Planned Procedure Date: [Scheduled date or TBD]

Planned Venue: [office / ASC / hospital]

Author/Role: [Name, credentials]

Referring Provider: [Name and specialty] (Include if applicable)

Preoperative Snapshot

Planned Procedure(s): [List each procedure with exact site, laterality, and tooth numbers as applicable; clarify which are planned for this anesthetic event if staged]

Indication: [Primary diagnosis or reason for surgery in 1–3 lines; may reference HPI for details]

Planned Anesthesia: [local only / minimal sedation / moderate sedation / deep sedation / general anesthesia] (Include intended airway approach if relevant and note anesthesia provider if known, or state TBD with plan to finalize)

Key Risk Flags: [Anticoagulant/antiplatelet use, significant cardiopulmonary disease, OSA, difficult airway history, prior anesthesia complications, high-risk allergies, pregnancy testing plan, need for interpreter/surrogate] (Include only if significant risk flags are present; omit this field entirely if none)

History

Chief Concern

Pre-op evaluation for planned [procedure] due to [indication].

History of Present Illness

[Narrative describing onset, duration, pattern/triggers, severity, prior treatments, and objective anchors relevant to OMS such as impaction, infection signs, periodontal status, trauma timeline and occlusion concerns, or lesion characteristics including growth, pain, paresthesia, and ulceration; clearly state rationale for surgery now] (Use brief embedded lists only if multiple teeth/sites are involved)

Medical History

• [Condition] – [Control/status and relevance to surgical/anesthetic/healing/bleeding/infection risk]

(If none, document: "No significant past medical history.")

Surgical History

• [Prior surgery and date] (Emphasize head/neck procedures and any relevant to planned anesthesia/airway)

Anesthesia/Sedation History

[Prior anesthetics/sedations, tolerance, recovery, and any complications including PONV, malignant hyperthermia concern, difficult intubation, severe emergence agitation, aspiration, or allergic reactions] (Required when moderate/deep sedation or GA is planned; omit for local-only unless relevant history exists. If unknown and sedation/GA is planned, state: "Anesthesia history: unknown (patient unsure)")

Medications

[List current medications with doses/frequency] OR [See reconciled medication list, reviewed and verified today.]

High-impact medications: [Anticoagulants/antiplatelets, diabetes medications, chronic opioids/benzodiazepines, steroids/immunosuppressants/biologics, OTC NSAIDs/aspirin/supplements affecting bleeding or sedation] (If medication information is missing, include: "[Not documented - verify prior to procedure]")

Allergies

• [Allergen] – [Reaction type]
• [Non-drug allergies such as latex, chlorhexidine, adhesive, iodine] – [Reaction]

(If no known allergies, document "NKDA." If allergy status unknown, include: "[Not documented - verify prior to procedure]." This section must never be omitted.)

Social History

• [Tobacco/vaping use and quantity/duration]
• [Alcohol use pattern]
• [Cannabis or other recreational drug use, route, frequency and relevance to sedation/anesthesia]
• [Escort availability and transportation plan] (Include for sedation cases)

Review of Systems

[Focused positives/negatives relevant to perioperative risk or diagnosis such as fever/constitutional symptoms for infection, or snoring/witnessed apneas/daytime somnolence for airway risk] (Include only if findings affect perioperative risk or diagnostic confidence; omit if non-contributory)

External Records Reviewed

[Summary of outside notes/testing reviewed with dates and key conclusions, such as cardiology clearance, anticoagulation management plan, or PCP clearance] (Include if applicable)

Physical Examination

Vitals

• BP: [value]
• HR: [value]
• RR: [value]
• SpO2: [value]
• Temp: [value]
• Height: [value]
• Weight: [value]
• BMI: [value]

(Required when sedation/GA is planned; recommended otherwise. Include height/weight/BMI when sedation is planned or when obesity impacts risk.)

General Appearance

[Appearance, distress level, ability to cooperate/communicate]

Airway Assessment

• Mouth opening: [measurement in mm or finger breadths]
• Mallampati: [Class I / II / III / IV]
• Neck mobility: [full / limited]
• Thyromental distance: [measurement in cm]
• Dentition/prostheses/loose teeth: [findings]
• Prior airway difficulty indicators: [findings]

(Required when moderate/deep sedation or GA is planned; optional for local-only)

Cardiopulmonary Examination

• Cardiac: [Rate/rhythm, murmurs, gallops, peripheral edema]
• Respiratory: [Breath sounds, work of breathing]

(Required when sedation/GA is planned; optional for local-only)

Head/Neck and Neurologic

• TMJ/trismus: [Interincisal opening, tenderness, deviation]
• Cranial nerves: [Findings, especially V2/V3 or VII if paresthesia risk exists]
• Neck: [Masses, lymphadenopathy, tenderness]

Oral and Maxillofacial Examination

• Mucosa/gingiva: [Inflammation, ulceration, lesions, pathology descriptors]
• Swelling/drainage/vestibular fullness: [findings]
• Periodontal status relevant to surgery: [findings]
• Occlusion/bite changes: [findings] (For trauma/orthognathic cases)
• Lymph nodes: [findings]
• Palpation findings: [Induration, fluctuation, tenderness]
• Tooth-specific findings with tooth numbers: [Caries, restorability, mobility, pericoronal inflammation, fracture lines]

Imaging

Type/Date: [Panoramic, periapicals, CBCT, CT, MRI with dates and adequacy/limitations]

Key Findings: [Root morphology, sinus proximity, IAN canal relationship to roots, pathology characteristics, fracture pattern, hardware position; include tooth numbers and anatomic subsites consistent with planned procedure]

(Always include if imaging exists; otherwise document planned imaging)

Diagnostics

• Labs: [Type, date, results]
• ECG: [Findings if obtained]
• Pregnancy test: [Result/date / Not indicated per policy / Not documented - verify prior to procedure]
• Consult results/cultures: [Findings if applicable]

(Include only if performed/available and relevant; omit this entire section if none obtained or indicated)

Assessment

Diagnoses

• [Primary surgical diagnosis with tooth numbers/anatomic sites]
• [Secondary diagnoses impacting perioperative course, ordered by significance]
• [Differential diagnosis if uncertain]

Perioperative Risk Stratification

• ASA physical status: [I / II / III / IV / V]
• Airway risk: [Anticipated easy / potentially difficult] – [basis from exam/imaging/history]
• Bleeding risk: [Anticoagulant/antiplatelet status, coagulopathy, management plan]
• Infection risk: [Immunosuppression status, endocarditis prophylaxis considerations per protocol]
• Aspiration/NPO risk: [NPO status/plan; reflux/other risk factors] (If sedation/GA planned and NPO status unknown: "[Not documented - verify prior to procedure]")
• Venue appropriateness: [Office / ASC / Hospital] – [rationale based on comorbidities and planned anesthesia]

(Include when sedation/GA is planned or when venue choice is non-trivial; optional for straightforward local-only cases)

Plan

Procedure Details

[Planned procedure(s) with tooth numbers, sites, and laterality; approach details for scheduling/consent including extraction complexity, flap design, hardware needs, grafts, biopsy with specimen handling/pathology plan, and special equipment requirements]

Anesthesia/Sedation Plan

[Intended level, planned monitoring, airway approach, rescue/escalation availability, post-anesthesia recovery expectations, observation needs, and escort requirement] (Include when sedation/GA is planned; omit for local-only)

Preoperative Instructions

• NPO/fasting: [Clear liquids cutoff time, solids cutoff time] (If sedation/GA planned and not established: "[Not documented - verify prior to procedure]")
• Medication management: [Medications to continue]; [Medications to hold with timing, especially anticoagulants/antiplatelets and diabetes medications]
• Pre-op testing/consults: [Ordered items / Not indicated; who will finalize outstanding items]
• Smoking/vaping cessation counseling: [Provided] (If applicable)
• Escort/transportation: [Confirmed / Not confirmed - verify prior to procedure] (For sedation cases)

Risks, Benefits, and Alternatives Discussion

Risks, benefits, and alternatives including no treatment were discussed. Patient questions were answered and understanding was assessed.

• Material procedure-specific risks discussed: [bleeding / infection / pain / swelling / bruising / nerve injury/paresthesia (IAN / lingual / infraorbital) / sinus communication / adjacent tooth damage / need for additional procedures / retained roots / fracture]
• Anesthesia-specific risks discussed: [respiratory depression / aspiration / hypotension / allergic reactions / PONV] (For sedation/GA cases)
• Consent status: [Consent signed today / Consent to be signed day of surgery] (Do not infer completion if pending)

Postoperative Plan

• Disposition: [Same-day discharge / Observation / Admission]
• Pain management: [Non-opioid regimen; opioid plan if indicated]
• Antibiotics: [Regimen and duration / Not indicated]
• Follow-up: [Timeframe and contact information for concerns or complications]

Safety Verification

• Identity verified using two identifiers: [Yes / No / Not documented - verify prior to procedure]
• Procedure/site/tooth numbers verified against imaging: [List verified tooth numbers and sites]
• Imaging available and correctly labeled for day-of use: [Yes / No]
• Site-marking/tooth-identification plan: [Description of marking/verification workflow]
• Interpreter used: [Language and interpreter ID] (If applicable)
• Guardian/surrogate: [Name, relationship, and authority] (If applicable)

(Include when procedure is scheduled)