Preoperative History & Physical (Surgery)

Note Type: [Preoperative H&P / Pre-op H&P Update]
Date/Time of Evaluation: [Date and time]
Location: [clinic / inpatient / day-of-surgery unit / other: specify]
Planned Procedure: [Procedure name with laterality and approach]
Indication/Diagnosis: [Primary surgical indication or diagnosis]
Surgeon/Service: [Operating surgeon and service]
Planned Date: [Date / Unknown]
Urgency: [elective / urgent / emergent]
Anticipated Anesthesia Type: [general / regional / MAC / local / unknown]
Expected Disposition: [outpatient / admit to floor / ICU / unknown]

(Select one pathway below based on Note Type. If "Preoperative H&P," complete the Full Pre-op H&P sections. If "Pre-op H&P Update," skip to the H&P Update Module.)

Source of History

[Historian and reliability] (Specify patient/family/caregiver/record review; include interpreter use if applicable; note any limitations to data reliability.)
[Key outside records reviewed, if any] (List sources with dates and high-yield takeaways.)
[Information gaps] (If medication list or other critical info is incomplete, explicitly state what is unknown.)

Chief Concern

[One-line reason for pre-op evaluation]

History of Present Illness

[Surgical diagnosis and symptom course] (Duration, severity, functional impact; prior treatments and responses; key diagnostic findings with dates; rationale for surgery at this time.)

[Current clinical stability and red flags] (Include active symptoms that might defer surgery: fever, cough, dysuria, skin changes, chest pain, new neurologic symptoms.)

[Baseline functional status] (State METs or functional capacity as relates to perioperative risk.)

Past History

Past Medical History: [Problem list with brief status notes] (Focus on surgery/anesthesia-relevant conditions: cardiovascular, pulmonary including OSA and CPAP use, neurologic, renal/hepatic, endocrine including diabetes control and chronic steroids, hematologic including bleeding disorders and prior VTE, GI aspiration risk, infectious history such as MRSA colonization, and implanted devices with type and managing team. If no chronic conditions, state "No known chronic medical conditions.")

Past Surgical History: [Prior operations with approximate year] (Note any history of difficult intubation, difficult IV access, anesthesia awareness, or severe PONV.)

Anesthesia/Family History: [Personal or family history of malignant hyperthermia, pseudocholinesterase deficiency, or severe anesthetic reactions] (If none known, state "None known.")

Medications

[Current medications with generic name, dose, route, frequency, and perioperative instruction: continue/hold/adjust with timing] (If list is incomplete, document best available source and note discrepancies.)

Anticoagulants/Antiplatelets: (Complete for each agent if applicable.)

• Agent: [Drug name and dose]
• Indication: [AF / mechanical valve / recent stent / VTE / other]
• Last dose: [Date and time]
• Hold plan: [Stop date, restart timing framework]
• Bridging: [Yes/No with rationale]
• Procedure bleeding risk: [low / moderate / high]
• Patient thrombotic risk: [Summary]
• Plan owner: [Coordinating service if applicable]

(If unknown, state "Unknown" and assign follow-up in Plan. Repeat for additional agents.)

Diabetes Agents: (If applicable.)

• [Insulin regimen and day-of-surgery adjustment plan]
• [Oral/non-insulin agents with hold/continue plan and timing]
• [SGLT2 inhibitor: stop date per protocol if applicable]
• [GLP-1 receptor agonist: drug, dose, dosing schedule, GI symptoms present/absent, perioperative plan per institutional protocol]

Allergies

[Drug/agent — reaction type and severity] (Include latex, adhesive, iodine, chlorhexidine sensitivities if applicable. Only use "No Known Drug Allergies" if explicitly confirmed.)

Social History

• Tobacco/vaping: [Current / former / never; pack-years if available]
• Alcohol: [Use pattern; withdrawal risk if applicable]
• Other substances: [Type, frequency, last use] (If applicable.)
• Living situation/support: [Post-op support availability]
• Functional status: [Baseline mobility/ADLs, assistive devices]
• Frailty markers: [Falls, unintentional weight loss] (Include when relevant.)
• Pregnancy status: [Status] (When applicable.)

Review of Systems

(Focused perioperative ROS. Only document items actually elicited; do not auto-populate negatives.)

• Cardiopulmonary: [Chest pain, dyspnea on exertion, orthopnea, palpitations, syncope]
• Infection: [Fever, cough, dysuria, skin infection]
• Bleeding/Clotting: [Easy bruising, prior surgical bleeding, melena/hematochezia]
• GI/Aspiration: [Reflux, dysphagia, nausea/vomiting]
• Neurologic: [New deficits]

Physical Examination

(Only document elements actually examined. If deferred, state "Deferred" with reason.)

• Vitals: [BP, HR, RR, SpO2, Temp, weight/BMI] (Note abnormal vitals with brief interpretation.)
• General: [Appearance, distress level, hydration]
• Airway: [Mouth opening, dentition, neck ROM, features affecting mask fit or intubation]
• Cardiovascular: [Rhythm, rate, murmurs if clinically significant]
• Pulmonary: [Breath sounds, work of breathing]
• Surgical Site/Focused Exam: [Findings relevant to planned procedure; skin integrity; infection signs; neurovascular status as applicable]

Diagnostic Data Reviewed

(List only tests actually reviewed and relevant to perioperative planning. Include dates. Mark pending items with responsible party.)

• Labs: [CBC, CMP, coag, A1c, type & screen as relevant — with dates]
• ECG: [Date, key findings]
• Imaging: [Modality, date, pertinent findings]
• Specialist Consultations: [Service, date, key recommendations]
• Pending: [Test and responsible party for follow-up]

Assessment

[Summary paragraph] (Restate surgical indication, key comorbidities influencing perioperative risk, and current clinical stability. Note any active issues that must be addressed before proceeding.)

[Problem list organized by perioperative importance] (Active/unstable issues first, then high-impact chronic conditions, then medication-dependent and procedure-specific risks.)

Plan

(Organize by clinical problem. Each item should include actionable steps, responsible party, and timing. Avoid vague statements such as "cleared for surgery" without specific mitigation. Address applicable issues from among: cardiovascular risk assessment and medication management, pulmonary/OSA optimization and CPAP plan, anticoagulation hold/restart/bridging and VTE prophylaxis, diabetes day-of-surgery management, aspiration risk and NPO plan, active infections, pain/PONV/disposition planning.)

[Problem-based plan items]

Risk Discussion: [If elevated risk, document specific risks discussed, patient understanding, and agreement to proceed] (Include only when applicable.)

Information Gaps/Tasks: [Items marked unknown and who will obtain, with timing]

Follow-up: [Next steps and communication plan with surgical/anesthesia teams]

Perioperative Checklist

• Surgical consent: [Obtained / Not yet obtained]
• Laterality/site verification: [Confirmed / Pending]
• Blood products: [Consent status; type & screen status]
• Advance directive/code status: [Status and perioperative plan if relevant]
• Device documentation: [Available / N/A]

H&P Update Module

(Use only when Note Type is "Pre-op H&P Update" and a valid full H&P exists within the allowable timeframe. Omit full H&P sections above.)

Reference: [Prior H&P author, date] — Reviewed and confirmed.

Interval History: [Changes since prior H&P: new symptoms, ED visits, hospitalizations, medication changes] (If none, state "No interval changes.")

Focused Exam Update: [Current vitals] — [Pertinent exam findings]

Medication Confirmations: [Last dose date/time for time-sensitive medications: anticoagulants, antiplatelets, insulin, GLP-1 RAs]

Confirmation: [Procedure, laterality, consent status verified]

Plan: [Updates to original plan, or "Proceed per original plan"]

(If any required information is unavailable or not elicited, document "Unknown" or "Not available" with reason, and add follow-up task in Plan when clinically important.)