Patient Profile
Date of Birth (D.O.B.)_________ BP_________ Age_______
Pulse___________ Height____________ Weight__________
Respiratory___________ Temp_________
Date of Surgery (D.O.S.)________________
Diagnosis: (ICD code)
Procedure: (CPT code)
Indication: pain, deformity, pressure, ulcer, tumor, wound, infection, elective surgery?
Past History:
- Cardiovascular
- pulmonary
- GI
- Neuro
- Heme
- Endocrine
- Previous Surgery
- Allergies
- Medications (currently taking)
Physical Exam:
ASA Classification: I- normal, II-systemic disease, III-severe(DM, HTN, obese, MI), IV-life threatening (stent, ESRD), V-not surviv without surgery, VI-declared brain dead
Anesthesia: under local, MAC, general, spinal
Lab Tests: blood, EKG, CBC, BMP
Hemostasis: Tourniquet @ ankle or thigh level
Position: Supine, Prone, Lateral
Resident:______________________________ Signature:_______________________________
Doctor:_______________________________ Date:_________________ Time:_____________________
PREOP CHECKLIST
– Transportation: [________]
– Preadmit [________] or Same day surgery [________] or Hoptel [________]
– CBC CMP PT/INR within 1 month: Done on [________] or Ordered [________]
– Type and Screen/Cross: Ordered [________]</span
– EKG within 4 months: Done on [________] or Ordered [________]
– CXR within 6 months: Done on [________] or Ordered [________]
– Antiplatelet/anticoagulation plan: [________]
– Medication Reconciliation done?
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