Preoperative History & Physical (Plastic Surgery)

Patient: [Patient full name]    DOB: [Date of birth]    MRN: [Medical record number]    Age: [Years]

Date/Time of Evaluation: [Date and time]    Location: [clinic / ASC / hospital]

Planned Procedure(s): [Procedure name(s) with laterality/site if applicable]    Indication: [reconstructive / cosmetic] — [Primary diagnosis]

Proposed Surgery Date: [Date]    Facility: [Facility name]

Surgeon(s): [Surgeon name(s)]    Planned Anesthesia: [general / regional / MAC / local / TIVA / unknown]

Source of History: [patient / family / medical records / interpreter]    History Reliability: [reliable / limited by (specify)]

Reason for Visit

[Chief concern, surgical intent, and patient goals] (1–3 sentences stating preoperative evaluation for specific procedure; elective cosmetic vs reconstructive; primary vs revision; urgent vs nonurgent.)

History of Present Illness

[Narrative description of the condition being treated: onset, course, severity, functional impact, and context relevant to the planned procedure] (1–2 paragraphs.)

[Prior treatments and outcomes including operations, injections, wound care, radiation, or other interventions with dates and response/complications]

[Patient goals and expectations] (Document specific aesthetic or functional goals.)

• Breast surgery (if relevant): [Prior breast surgery, implant details, radiation history, oncologic history, lymphedema]
• Body contouring (if relevant): [Weight history and stability duration, rashes/intertrigo, bariatric surgery history, hernia symptoms]
• Facial procedures (if relevant): [Prior facial/nasal/oculoplastic surgery, nasal obstruction, visual field complaints, ocular dryness]
• Wound/reconstruction (if relevant): [Wound duration, vascular status, infection history, prior cultures, imaging summary, oncologic status]

Medical Necessity (Include only if applicable for payer authorization): [Symptoms and duration; failed conservative therapy; objective findings; functional impact; reference attached tests/photos]

Past History

Past Medical History: [Relevant conditions with qualifiers] (Emphasize cardiopulmonary disease, diabetes with A1c, OSA with CPAP use, VTE/hypercoagulability history, bleeding disorders, immunosuppression/chronic steroids, nicotine dependence with cessation status. For safety-critical unknowns, state "Unknown—verify prior to proceeding.")

Past Surgical History: [Prior surgeries with dates, emphasizing procedures in operative field] (Include anesthesia complications: difficult airway, PONV, malignant hyperthermia, awareness, ICU admission.)

Family History: [Malignant hyperthermia, pseudocholinesterase deficiency, VTE/hypercoagulability, bleeding disorders] (Omit section if none relevant.)

Social History: [Tobacco/nicotine: type, last use, cessation plan] — [Alcohol use and withdrawal risk] — [Substance use relevant to anesthesia] — [Postoperative support/escort availability] — [Occupation/activity demands]

OB/GYN: [LMP] — [Pregnancy test result and date] — [Breastfeeding status] (Include for patients of childbearing potential.)

Medications and Allergies

Current Medications: [Medication list with dose and frequency] (Identify anticoagulants/antiplatelets with indication and prescriber; OTC NSAIDs; supplements/herbals with bleeding risk; weight-loss agents; chronic opioids/benzodiazepines.)

Allergies: [Allergen and reaction type] (Include latex, chlorhexidine, adhesive, suture sensitivities. If unknown, state "Unknown—verify prior to proceeding.")

Perioperative Medication Plan:

• Anticoagulant/antiplatelet: [Continue/hold/bridge; last dose; resume timing; prescriber coordination]
• Diabetes regimen: [Insulin/oral agent adjustments; day-of-surgery instructions]
• GLP-1 receptor agonist: [Last dose; aspiration risk assessment; hold/resume plan; anesthesia coordination]
• Chronic steroids: [Stress-dose plan if indicated]
• Other medications: [ACE/ARB, diuretics, beta-blockers, NSAIDs, supplements; continue/hold status]
• Antibiotic prophylaxis: [Agent and timing, or state per protocol]

Review of Systems

(Targeted perioperative review. Do not auto-populate negatives for systems not assessed.)

• Constitutional: [Fever/chills, weight change, fatigue]
• Cardiac: [Chest pain, orthopnea, edema, syncope, palpitations]
• Pulmonary: [Dyspnea, cough, wheeze, recent URI]
• GI: [Reflux/GERD, aspiration risk]
• Neurologic: [Stroke/TIA history, seizures]
• Hematologic: [Easy bruising/bleeding, prior transfusions]
• Skin: [Rashes, wounds, ulcers at surgical site]
• Psychiatric: [Anxiety, adherence concerns, body image concerns]

Physical Examination

Vitals: BP [value], HR [value], RR [value], Temp [value], SpO2 [value], Ht [value], Wt [value], BMI [value]

General: [Appearance, distress level, functional status]

Cardiovascular: [Rate/rhythm, murmurs, edema]

Pulmonary: [Breath sounds, work of breathing]

Airway: [Mallampati class, mouth opening, neck mobility, dentition, beard, prior airway concerns] (Include for office-based surgery or high-risk patients.)

Surgical Site Examination: [Baseline findings relevant to planned operation] (Include prior scars, skin quality/perfusion, radiation changes, measurements as applicable, signs of infection/rash/ulceration, neurovascular status near operative field.)

Photos: [obtained / not obtained] (If obtained, note storage location.)

(For areas not examined, state "Not examined—[reason]" rather than defaulting to normal.)

Diagnostic Data

• Labs: [Test name, date, key result] (Include CBC, BMP, coags, A1c, pregnancy test as indicated.)
• ECG/Cardiac testing: [Date, summary, implications]
• Imaging: [Date, summary]
• Specialist clearances: [Consultant, date, conclusion, impact on plan]
• Pathology/cultures: [Date, result] (If applicable.)

(Document what was reviewed and impact on plan, or state "Reviewed, no change to plan.")

Risk Stratification

Cardiac Risk: [Method used] — [Risk estimate] — [Functional capacity in METs] — [Implications and need for further testing]

Pulmonary/OSA Risk: [OSA screening tool and result] — [CPAP use/compliance] — [COPD/asthma optimization status] — [Risk mitigation]

VTE Risk: [Stratification method] — [Risk level] — [Prophylaxis plan: mechanical and/or chemoprophylaxis with timing/duration] (Document rationale if deviating from protocol.)

Wound Healing Risk: [Nicotine status, diabetes control, nutritional status, prior radiation, immunosuppression] — [Mitigation plan]

Disposition: [outpatient / planned admission] — [Overnight monitoring needs if applicable]

Clearances and Optimization

• [PCP medical clearance] — [completed / pending / not needed]
• [Cardiology clearance] — [completed / pending / not needed]
• [Pulmonology clearance] — [completed / pending / not needed]
• [Hematology consult] — [completed / pending / not needed]
• [Smoking/nicotine cessation] — [completed / pending / not needed]
• [Glycemic optimization] — [completed / pending / not needed]
• [Nutritional optimization] — [completed / pending / not needed]
• [Medication coordination] — [completed / pending / not needed]

Perioperative Plan

Surgical Plan: [Final procedure(s) with site/side; staging if applicable; special equipment/implants/drains; skin prep considerations; positioning]

Anesthesia Coordination: [Anticipated anesthesia type; airway concerns; aspiration risk mitigation; NPO confirmation]

VTE Prophylaxis: [Mechanical measures] — [Chemoprophylaxis agent/dose/timing if indicated]

Pain Management: [Multimodal regimen; regional techniques; opioid-sparing strategy; bowel regimen if opioids anticipated; plan for chronic opioid users]

Postoperative Care: [Discharge criteria; expected LOS; wound/drain care; activity restrictions; follow-up schedule; contingency instructions]

Consent and Safety Verification

Procedure Consent: [obtained / pending] — [Location of signed document]

Anesthesia Consent: [obtained / per anesthesia workflow]

Site/Side Verification: [Correct procedure/site/laterality documented; surgical marking planned per protocol]

Advance Directives: [DNR status and perioperative plan] (Include if applicable.)

Assessment and Plan

1. [Primary surgical diagnosis]: [Assessment and plan]
2. [Anticoagulation management]: [Assessment and plan]
3. [Cardiovascular risk]: [Assessment and plan]
4. [OSA/pulmonary risk]: [Assessment and plan]
5. [Diabetes management]: [Assessment and plan]
6. [Smoking cessation]: [Assessment and plan]
7. [VTE prophylaxis]: [Assessment and plan]
8. [Additional problems]: [Assessment and plan]

Readiness for Surgery: [No contraindication to proceed provided pending items completed: (list pending items)] / [Not optimized for elective surgery due to (reason); defer until (condition met)]

H&P Update / Interval Assessment

(Use on day of surgery when valid recent H&P exists.)

Reference: [Prior H&P date and author]

Interval History: [No change since prior H&P / Summary of interval changes including new symptoms, infections, hospitalizations, medication changes]

Examination: [Targeted exam findings] — Vitals: BP [value], HR [value], RR [value], Temp [value], SpO2 [value]

Medication Confirmation: [Anticoagulant/antiplatelet last dose] — [Diabetes medication compliance] — [GLP-1 status if applicable]

NPO Status: [Time of last solids] — [Time of last clear liquids]

Verification: [Planned procedure with site/side confirmed] — [Consent status confirmed]

Assessment: [Proceed with planned procedure / Delay or cancel: (reason and plan)]