Preoperative H&P (Gynecologic Surgery)

Note Type: Preoperative History & Physical (Gynecologic Surgery)

Date/Time: [Date and time of documentation]

Author: [Author name, credentials, role]

Patient Name: [Full name]

DOB: [Date of birth]

MRN: [Medical record number]

Planned Surgery Date: [Scheduled date]

Surgical Facility: [Facility name]

Primary Surgeon: [Surgeon name]

Admitting Service: [Service or department]

Planned Procedure

• Procedure name(s): [REQUIRED - Primary procedure; secondary/contingent procedures if planned]
• Approach/route: [vaginal / laparoscopic / robotic / open]
• Laterality/site: [Side or site, if applicable]
• Primary indication: [Diagnosis prompting surgery]
• Anticipated anesthesia: [general / regional / MAC / local with sedation]
• Implants or special devices: [Planned devices or implants, if applicable]

Reason for Surgery

[Patient-centered surgical goal describing the problem surgery intends to address and desired outcome] (Include a direct patient quote regarding goals or preferences only if explicitly stated; do not infer goals.)

History of Present Illness

[Narrative summary: onset, duration, severity, and current impact of symptoms; prior treatments and responses; relevant workup reviewed with study type, date, and key impression; rationale for surgery now] (If outside records are pending, document what is missing and whether it affects surgical readiness.)

Alternatives Discussed

• [Non-operative management option] — [Tradeoffs discussed and reason declined or accepted]
• [Less invasive procedural alternative] — [Tradeoffs discussed and reason declined or accepted]
• [Expectant management, if reasonable] — [Rationale and reason declined or accepted]

(List only alternatives that were actually discussed; do not use generic language without naming specific alternatives.)

Informed Consent

• Risks discussed: [General risks: bleeding, infection, organ injury, anesthesia risks, VTE, conversion to laparotomy if applicable; procedure-specific risks]
• Benefits: [Expected outcomes and symptom relief]
• Patient understanding: [Confirmation that questions were answered; concerns raised if any]
• Consent status: [REQUIRED - Signed consent on file / Not yet signed with plan and timeline] (Note interpreter use if applicable.)

Fertility/menopause counseling: [Discussion of fertility desires, impact on fertility and ovarian function, ovarian conservation versus removal, hormone therapy considerations] (Include only when uterus, tubes, or ovaries are involved.)

Sterilization counseling: [Discussion of permanence, alternatives, regret risk; consent form status and timing requirements] (Include only when permanent sterilization is planned.)

Morcellation counseling: [Tissue extraction plan, containment system use, occult malignancy risk discussion] (Include only when power morcellation is planned.)

Medical, Surgical, and Gynecologic History

Past Medical History: [Conditions affecting perioperative risk]

Past Surgical History: [Prior abdominal/pelvic surgeries, complications, known adhesions]

OB/GYN History: [Gravida/para, delivery modes, LMP or menopausal status, contraception, future fertility desires, relevant Pap/HPV history]

Medications: [Current medications; note anticoagulants, antiplatelets, hormones, GLP-1 agonists, chronic steroids, SGLT2 inhibitors]

Allergies: [REQUIRED - Allergies with reaction type; include latex, iodine, chlorhexidine status]

Social History: [Tobacco, alcohol, substance use; support person; pregnancy risk if applicable]

Review of Systems

[Perioperatively relevant findings: cardiopulmonary symptoms, VTE history or symptoms, active infection signs, bleeding or bruising history] (Include only if pertinent positives or negatives were assessed; omit section if comprehensive ROS was not performed.)

Physical Examination

• Vitals: [Most recent vitals with date]
• General: [Appearance, distress level]
• Cardiovascular: [Rate, rhythm, murmurs]
• Pulmonary: [Breath sounds, effort]
• Abdomen: [Scars, tenderness, masses, hernias]
• Extremities: [Edema, DVT signs if symptomatic]
• Pelvic exam: [Speculum and bimanual findings: cervix, uterine size and mobility, adnexa, prolapse staging as applicable / Deferred with reason] (Include only if it affects surgical planning.)
• Chaperone: [Name and role / offered and declined]

Data Reviewed

• Labs: [CBC, BMP, pregnancy test, type and screen as applicable with date and key values]
• Imaging/pathology: [Study type, date, and actionable impression]
• VTE risk category: [Assessment tool used and resulting category]
• Clearances/consults: [Specialty, date, and key recommendations]

Assessment

[Synthesis of primary diagnosis and surgical indication; key comorbidities affecting perioperative risk; surgical readiness status; outstanding optimization items if any] (Aim for 3–5 sentences.)

Plan

Surgical Plan: [Procedure with route and contingencies; anticipated specimens; special equipment or intraoperative consults; expected disposition: same-day discharge / admission with anticipated length of stay]

Medical Optimization: [Pending optimization items: anemia management, infection clearance, glycemic or blood pressure targets; medication management: anticoagulant hold timing with bridging plan if needed, stress-dose steroids if applicable, GLP-1 agonist and SGLT2 inhibitor holds per protocol; pregnancy testing plan and timing] (Omit items that do not apply.)

VTE Prophylaxis Plan: [REQUIRED - Risk assessment method and category; mechanical prophylaxis type and timing; pharmacologic prophylaxis if indicated with agent, dose, timing, and renal/weight adjustments; duration: in-hospital only / extended; contraindications if pharmacologic prophylaxis withheld]

Antibiotic Prophylaxis Plan: [REQUIRED - Drug and dose, timing relative to incision, re-dosing plan for prolonged cases, allergy alternative if applicable; adjuncts such as vaginal prep or CHG bathing per protocol]

Day-of-Surgery Update

(Include this section only when the H&P is performed more than 24 hours before surgery.)

• Interval history: [New symptoms or illness, medication changes, last oral intake, last anticoagulant dose]
• Interval vitals: [Most recent values]
• Procedure confirmation: [Procedure name and laterality match consent]
• Consent form: [On chart and verified / Plan to obtain prior to surgery]
• Pregnancy test: [Result if obtained / Plan to obtain prior to anesthesia]
• Conclusion: [No changes; proceed as planned / Modifications: (specify)]