Pre-Procedure History-Physical Examination Form (Page 2 of 2) in pdf

One Medical Center Drive, Lebanon, NH 03756

Pre-Procedure

History & Physical Examination

Addressograph

Physical Exam (Complete each item. Explain abnormal.)

Height: ___________

Weight: ___________ (kg)

Vital Signs:

BP: __________

P: __________

R: __________

T: __________

Normal

Abnormal

Not Examined

Explanations



Constitutional/General



Neurologic



EENT & Mouth



Neck/Thyroid



Skin



Musculoskeletal



Lungs



Heart



Peripheral Vascular



Breasts and Axillae



Abdomen



Pelvic



Scrotum/Testes



Rectal

Pertinent Data: ______________________________________________________________________________________________________

______________________________________________________________________________________________________________________

Assessment/Plan: ___________________________________________________________________________________________________

______________________________________________________________________________________________________________________

Pre-Procedure Orders:



Pre-Anesthesia Consult (schedule through Pre-Admission Testing): Required for non-emergency patients for

whom Anesthesia Services are anticipated if patient has DNR or Limited Resuscitation Order or Out-of-

Hospital DNR Order. Consult is recommended but optional prior to 12/31/08.



__________________________________________________________________________________________________________________



__________________________________________________________________________________________________________________



__________________________________________________________________________________________________________________

Examiner Signature: ______________________________ Print Name: _________________________ Date: ____________ Time: _________

24-Hour Interval H&P

Code Status: _________________________



Condition changed (see note)

Condition unchanged since H&P originally performed

For DNR or Limited Resuscitation status Patients: “Documentation of Patient wishes during the peri-procedural

time period for Patients with: DNR or Limited Resuscitation Order or Out-of-Hospital DNR Order” form



Completed

Not Completed (optional prior to 12/13/08)

Examiner Signature: ______________________________ Print Name: _________________________ Date: ____________ Time: _________

H&P Review by DHMC Attending Physician

I have reviewed the pre-procedure H&P and subsequent interval H&P, as applicable and



Find no need to add additional information



Would add the following information: _________________________________________________________________________________

Signature: ___________________________________ Print Name: _____________________________ Date: ___________ Time: __________

Page 2 of 2

Original to medical record – Tab 4: Inpatient Notes

Approved by OCA 8/08

RM/HIS 11-3-08

Rev. 10/08, 5-2-11

F-629

Pre-Procedure History-Physical Examination Form Page 2

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