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.

Patient Information

Name:	Age:
Gender:	Date of Birth:
Medical Record Number:	Date of Evaluation:

Medical History
Previous surgeries:	Past medical conditions:
Current medications:	Allergies:
Physical Examination
Vital signs:	Height:
Weight:	BMI:
Laboratory Tests
CBC:	BMP:
Coagulation studies:	ECG:
Chest X-ray:	Other tests:
Assessment of Surgical Risk
Surgical risk:	Cardiac risk:
Pulmonary risk:	Bleeding risk:
Anesthetic Considerations
Airway assessment:	Anesthesia type:
Special Considerations
Pregnancy status:	Smoking/alcohol/drug use:
Psychological assessment:	Additional consultations:
Discussion and Consent
Risks and benefits:	Informed consent:
Plan
Medical optimization:	Medication management:
Special instructions:	Follow-up:
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.

Comments & Notes