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PATIENT HISTORY AND PHYSICAL EXAM: IF YOUR OFFICE DOES NOT MEDICALLY CLEAR PATIENTS FOR SURGERY, PLEASE DO NOT COMPLETE THE APPOINTMENT AND EDUCATE THE PATIENT TO GO ELSEWHERE FOR SURGICAL CLEARANCE
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Preoperative history and physical (preop H&P) is a comprehensive assessment of a patient's medical history and current health status that is conducted before surgery to identify any potential risks and plan for safe anesthesia and surgical procedures.
Typically, the healthcare provider performing the surgery, such as a surgeon or anesthesiologist, is responsible for filing the preop history and physical documentation.
To fill out a preop history and physical, healthcare providers should gather relevant patient information, including medical history, medications, allergies, and any previous surgeries. This information is documented in a standardized format, ensuring thoroughness and clarity.
The purpose of preop history and physical is to ensure the safety of the patient undergoing surgery by evaluating their overall health, identifying potential risks, and determining appropriate anesthesia and surgical approaches.
The preop history and physical must report the patient's medical history, current medications, allergies, vital signs, physical examination findings, and any relevant laboratory or imaging results.
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