Free Preoperative Evaluation Template
Preoperative Evaluation
Introduction
The preoperative evaluation is a crucial step in ensuring patient safety and optimizing surgical outcomes. This template provides a structured approach to assessing a patient's health status and surgical risk factors before undergoing a surgical procedure.
Overview
This preoperative evaluation template is designed to guide healthcare professionals in systematically gathering and documenting essential information related to a patient's medical history, physical examination findings, laboratory tests, surgical risk assessment, anesthetic considerations, special considerations, discussion and informed consent, and the plan of care. It aims to streamline the preoperative assessment process and enhance patient safety.
Instructions
Fill in the necessary information regarding the patient's medical history, including previous surgeries, current medications, allergies, and family history of anesthesia complications.
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Patient Information |
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Name: |
Age: |
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Gender: |
Date of Birth: |
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Medical Record Number: |
Date of Evaluation: |
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Medical History |
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Previous surgeries: |
Past medical conditions: |
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Current medications: |
Allergies: |
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Physical Examination |
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Vital signs: |
Height: |
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Weight: |
BMI: |
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Laboratory Tests |
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CBC: |
BMP: |
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Coagulation studies: |
ECG: |
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Chest X-ray: |
Other tests: |
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Assessment of Surgical Risk |
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Surgical risk: |
Cardiac risk: |
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Pulmonary risk: |
Bleeding risk: |
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Anesthetic Considerations |
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Airway assessment: |
Anesthesia type: |
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Special Considerations |
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Pregnancy status: |
Smoking/alcohol/drug use: |
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Psychological assessment: |
Additional consultations: |
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Discussion and Consent |
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Risks and benefits: |
Informed consent: |
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Plan |
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Medical optimization: |
Medication management: |
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Special instructions: |
Follow-up: |
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Next Evaluation: |
[Enter Date] |
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Thank you for completing the Preoperative Evaluation Form. Your responses will be kept confidential and used solely for evaluation purposes. Please return the form to the designated healthcare professional.
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Comments & Notes |
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