The importance of the preoperative history and physical

Abstract

www.ORNurseJournal.com AA 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, By Michelle R. Tinkham, MS, BSN, RN, PHN, CNOR, CLNC, RNFA The importance preoperative