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Pre-Op Clearance
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Date of Surgery
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Type Of Surgery
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Subjective
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HPI
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Review of Systems (WNL)
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Review of Systems (Abnormal)
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ROS Abnormal Free Text
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Medications
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Supplements
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Allergies
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Past Medical Hx
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Surgical History
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Social History
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Patient Height
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Weight (enter number only)
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Marital Status
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Children (if applicable)
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Smoking Status
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Additional Details (if applicable)
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Alcohol Use
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Additional Details (if applicable)
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Hx of Drug or Alcohol Abuse?
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Additional Details (if applicable)
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Activity
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Family History
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Objective
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Neurological Exam
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Mental Status- Within Normal Limits
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Mental Status- Abnormal
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Cranial nerves- Within Normal Limits
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Cranial Nerves- Abnormal
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Gait- Within Normal Limits
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Gait- Abnormal
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No pathologic reflexes
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Pathologic reflexes- Abnormal/Free text
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Motor- Within Normal Limits
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Motor- Abnormal/ Free Text
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Reflexes- Within Normal Limits
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Reflexes- Abnormal/ Free Text
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Sensory- Normal
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Sensory- Abnormal/ Free Text
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Objective Free Text
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Imaging
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XR
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Imaging Reviewed
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Labs/Other Studies
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Free Text
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Assessment
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Assessment
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Plan
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Free Text Box
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Orders
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Complete Blood Count (CBC)
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Basic Metabolic Panel
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Coagulation Studies: PT, PTT, and INR
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Urinalysis
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Chest X-Ray
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EKG
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SSRI Disclaimer
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Advised to stop ASA/NSAIDS/plant based herbs/supplements
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The patient is cleared for surgery
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Patient clearance pending
• • •
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