Get the free History and Physical Examination for Outpatient Surgery

This document is intended to be completed by the primary care physician for preoperative assessment of patients scheduled for outpatient surgery, detailing medical history, physical examination findings,

How to fill out history and physical examination

How to fill out History and Physical Examination for Outpatient Surgery

1. Begin with patient identification: Name, age, sex, and medical record number.
2. Document the chief complaint and reason for surgery.
3. Take a detailed medical history, including past medical, surgical, and family history.
4. Record current medications and any allergies the patient may have.
5. Conduct a thorough physical examination, noting vital signs, systems review, and any relevant findings.
6. Assess the patient’s functional status and any associated comorbidities.
7. Include laboratory and imaging results relevant to the procedure.
8. Document the surgical procedure planned and the anesthesia to be used.
9. Note any preoperative instructions and patient consent.
10. Sign and date the examination form.

Who needs History and Physical Examination for Outpatient Surgery?

1. Patients undergoing outpatient surgery require a History and Physical Examination to assess their medical history, current health status, and readiness for the procedure.
2. Surgeons and anesthesiologists need this examination to ensure patient safety and tailor the surgical approach.

People Also Ask about

What does a physical examination include?

A physical examination usually includes: Inspection (looking at the body) Palpation (feeling the body with fingers or hands) Auscultation (listening to sounds, usually with a stethoscope)

What are the 4 stages of clinical examination?

To develop a comprehensive understanding of a patient's condition, practitioners need to employ a systematic approach to physical examination that involves four primary techniques: inspection, palpation, percussion and auscultation.

What information is typically included in a patient's medical history?

Health information is the data related to a person's medical history, including symptoms, diagnoses, procedures, and outcomes. A health record includes information such as: a patient's history, lab results, X-rays, clinical information, demographic information, and notes.

What is the history and physical exam?

The H&P: History and Physical is the most formal and complete assessment of the patient and the problem. H&P is shorthand for the formal document that physicians produce through the interview with the patient, the physical exam, and the summary of the testing either obtained or pending.

What information must be included in the history and physical examination?

Patient age. diagnoses, the type and number of surgeries and procedures scheduled to be performed, comorbidities, and the level of anesthesia required for the surgery or procedure.

What are the 5 physical examination techniques?

Physical examination is a vital skill for health care professionals, such as nurses, paramedics, pharmacists, and health care assistants. It is the process of evaluating the physical condition of a patient by using observation, palpation, percussion, auscultation, and smell.

What is included in a comprehensive history and Physical?

A comprehensive history intake includes the patient's medical history, past surgical history, family medical history, social history, allergies, and medications.

What is the history and physical exam of a patient?

The H&P: History and Physical is the most formal and complete assessment of the patient and the problem. H&P is shorthand for the formal document that physicians produce through the interview with the patient, the physical exam, and the summary of the testing either obtained or pending.

For pdfFiller’s FAQs

What is History and Physical Examination for Outpatient Surgery?

History and Physical Examination (H&P) for Outpatient Surgery is a comprehensive evaluation performed by a healthcare provider to assess a patient's medical history and current health status before undergoing a surgical procedure. It includes reviewing the patient's past medical history, current medications, allergies, and any relevant physical examinations.

Who is required to file History and Physical Examination for Outpatient Surgery?

Typically, the surgeon or a qualified healthcare professional is required to file the History and Physical Examination for Outpatient Surgery. This may include physician assistants or nurse practitioners, depending on the healthcare facility's protocols and state regulations.

How to fill out History and Physical Examination for Outpatient Surgery?

To fill out the History and Physical Examination for Outpatient Surgery, a healthcare provider should start by documenting the patient's demographic information, conducting a detailed medical history interview, performing a physical examination, and recording findings in a structured format. It is essential to ensure that all sections of the form, including medical history, medications, allergies, and physical examination results, are completed accurately.

What is the purpose of History and Physical Examination for Outpatient Surgery?

The purpose of History and Physical Examination for Outpatient Surgery is to identify any potential risks or contraindications that may affect the patient's safety during surgery. It helps to ensure that the surgical team has a complete understanding of the patient's health status and can make informed decisions regarding the surgical procedure and anesthesia management.

What information must be reported on History and Physical Examination for Outpatient Surgery?

The information that must be reported on the History and Physical Examination for Outpatient Surgery includes the patient's medical history, current medications, allergies, significant past surgical history, family health history, the results of the physical examination, vital signs, and any relevant laboratory or diagnostic test results.