PRE-OPERATATIVE CONSULTATION TEMPLATE
General
Chief cardiac diagnostic reason for consult
Physician who requested consult
Type of surgery planned
History
Characterize the history of present illness OR status of chronic conditions
Past Medical History
Social History
Family History
ROS
(Questions asked of the patient)
Must have at least 10 systems or the reason that you are unable to obtain them
General
Skin
Head
Eyes
Ears
Nose/Sinuses
Mouth/Throat
Neck
Breasts
Respiratory
Cardiovascular
Gastrointestinal
Urinary
Male Genital
Female Genital
Musculoskeletal
Hematologic
Endocrine
Psychiatric
Examination
Vitals
General
Skin
HEENT
Neck
Thorax & Respiratory
Cardiac
Peripheral vascular
Abdomen
Musculoskeletal & Extremities
Neurological
Results
Lab Results
Studies
Assessment & Plan
Cardiac risk assessment - Is patient an acceptable risk for the surgery?