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HPI
|
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HPI/Chief Complaint
|
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Type of Surgery
• • •
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Indication for surgery
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Date of Surgery
|
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Prior Imaging/Studies/Tests
|
Smoker
|
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PAST MEDICAL HISTORY
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|
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Past Medical History
• • •
|
Past Medical History Freewrite
|
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PAST SURGICAL HISTORY
|
|
|
Past Surgical History
• • •
|
Comments
|
|
Social History
|
|
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Social History
|
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Alcohol
|
Comments
|
|
History Drug Use
• • •
|
|
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Other substances
|
|
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Review OF Systems
|
|
|
General [-]
|
General
• • •
|
|
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General Comments
|
|
Neck [-]
|
Neck
• • •
|
|
|
Neck Comments
|
|
Cardiovascular [-]
|
Cardiovascular
• • •
|
|
|
Cardiovascular Comments
|
|
Respiratory [-]
|
Respiratory
• • •
|
|
|
Respiratory Comments
|
|
GI [-]
|
GI
• • •
|
|
|
GI Comments
|
|
Periph. Vasc. [-]
|
Periph. Vasc.
• • •
|
|
|
Periph. Vasc. Comments
|
|
Genital (Female) [-]
|
Genital (Female)
• • •
|
|
|
Genital (Female) Comments
|
|
MSK [-]
|
MSK
• • •
|
|
|
MSK Comments
|
|
Neurological [-]
|
Neurological
• • •
|
|
|
Neurological Comments
|
|
Endocrine [-]
|
Endocrine
• • •
|
|
|
Endocrine Comments
|
|
Psychiatric [-]
|
Psychiatric
• • •
|
|
|
Psychiatric Comments
|
|
Physical Exam
|
|
|
General WNL
|
General Abnormal
• • •
|
|
Skin WNL
|
Skin Abnormal
• • •
|
|
Neck WNL
|
Neck Abnormal
• • •
|
|
Cardiovascular WNL
|
Cardiovascular Abnormal
• • •
|
|
Lungs WNL
|
Lungs Abnormal
• • •
|
|
Abdomen WNL
|
Abdomen Abnormal
• • •
|
|
MSK WNL
|
MSK Abnormal
• • •
|
|
Neuro WNL
|
Neuro Abnormal
• • •
|
|
Extremities WNL
|
Extrem Abnormal
• • •
|
|
Assessment
|
|
|
Assessment
|
|
|
Plan
|
|
|
Plan
|
Surgical Consent Obtained
|
|
NPO after 12am
|
|
|
Radiology
• • •
|
|
|
Labs
• • •
|
|
|
General Instructions
• • •
|
Treat and Goals
|
