The importance of the preoperative history and physical
Michelle R. Tinkham MS, BSN, RN, PHN, CNOR, CLNC, RNFA

$7.95 		OR Nurse 2013
May 2012 
Volume 6  Number 3
Pages 40 - 46
 
  PDF Version Available!

ABSTRACT
A history and physical, also known as an H&P, is essential for a complete preoperative evaluation. The H&P gives the surgical team a snapshot of the patient, pointing out preexisting conditions (such as cardiac complications) that may put the patient at risk for operative or postoperative complications. Many postoperative complications, such as delayed wound healing, can be linked to preexisting conditions, such as diabetes. This article provides an overview of the essential components to a successful H&P, alerts to watch for when reviewing the H&P, and recent regulation changes affecting the H&P.Although The Joint Commission (TJC) requires all surgical patients to have an H&P within 30 days before the planned surgery, the exact data and format aren't specified.1 Many facilities create a form for physicians to fill out; the form provides a framework for obtaining all the necessary information.The preoperative H&P is made up of three main parts: * the complete medical history and review of systems * a detailed head-to-toe physical exam with current vital signs * applicable diagnostic test results.The H&P also includes a listing of the patient's chief complaint, history of the present illness, surgical plan, and a risks, benefits, and alternatives statement. As with any piece of healthcare information, the H&P form should have the proper patient identification information, including the patient's name, date of birth, age, gender, medical record number, admission date, and the name of the physician completing the H&P. Because the form contains protected health information, access to it should be restricted to those persons involved with the patient's care.Every professional organization has guidelines for patient H&Ps. The three most relevant to the preoperative discussion are the Association of periOperative Registered Nurses (AORN), American Society of Anesthesiologists (ASA), and American College of Surgeons (ACS) guidelines. Specific recommendations may vary depending

Purchase Now !

To purchase this item, follow the instructions below. If you’re not already logged in, be sure to enter your login information below to ensure that your item is saved to your File Drawer after you purchase it.

Not a member? Join now for Free!


Cost:$7.95
1) If you're not already logged in, enter your information below to save this item in your File Drawer for future viewing.

User name:


Password


Forgot your user name or password? 		2)  If you have a coupon or promotional code, enter it
here.(If not, just click Continue.


Digital Coupon: (optional)

3)  Click Continue to go to the next screen, where
you'll enter your payment details.




Featured Jobs



Benefits of Membership

FREE E-Newsletters
Sign up for our free enewsletters to stay up-to-date in your area of practice - or take a look at an archive of prior issues

CESaver
Join our CESaver program to earn up to 100 contact hours for only $34.95
Register Now

Lippincott's NursingCenter.com
Explore a world of online resources

Become a Member