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CP# CP Eval: Covid RT-PCR: CC

SAMPLE PREOP FORM

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Bhi-An Batobalonos
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65 views2 pages

CP# CP Eval: Covid RT-PCR: CC

SAMPLE PREOP FORM

Uploaded by

Bhi-An Batobalonos
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as DOCX, PDF, TXT or read online on Scribd
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DE LA SALLE UNIVERSITY MEDICAL CENTER CP#

DEPARTMENT OF ANESTHESIOLOGY  CP EVAL:


PRE-OPERATIVE EVALUATION SHEET  COVID RT-PCR:
 CC:
TELECONSULT
Name: Date: Hospital No:
Age: Sex: Address: Religion: Room:

Assessment:
Proposed Surgery:
ASA PS 1 2 3 4 5 E
Anesthetic Plans:
Blood: Crossmatched ( ) FWB ( / ) PRBC ( ) __________
Premedications
Standby ( ) FWB ( / ) PRBC ( ) __________
Blood Type/Rh:
Technique:
Previous Operation/Complication:
Unexplained anesthetic/surgical morbidity/mortality in the family:

Perianesthetic History:
Last Meal
 HPN HBP: UBP:  IHD  CHF ___________  Valvular ___________
CVS
 Arrhythmia  others:
Neuro  CVD  Seizures  Psych d/o  others:
 Asthma Last attack: __________ URTI: ___________  PTB  COPD _______
Respiratory
 Pneumonia others:
Endocrine  DM Thyroid Disorder: others:
Renal  Insufficiency  Failure  Dialysis  others:
GI/Hepatic   GERD  others
Metabolic/  Anemia __________  Coagulopathy __________  Pregnant _____________  Arthritis ____________________
Infection/Others  HIV  others
Heredofamilial
Allergy  Medicine:  Food:
Exercise
Habits  Smoking Pack years: Last smoke:  Drinking:
Medications

Physical Examination: BMI:


Vital Signs BP: PR: RR: Temp: Wt: Ht:
Head and Neck Adequate mouth opening and TMD, pink palp conjunctiva
Airway Good air entry Mallampati 1 2 3 4 Dentures: ( )
Chest & Lungs Clear breath sounds
Cardiac NRRR, (-) murmurs
Abdomen Soft, Non-tender
Extremities FEPP
Back/ Genital (-) deformities
Neurological GCS 15 5/5 Motor 5/5 100% Sensory 100%

5/5 5/5 100% 100%

Diagnostics
Hgb Hct PLT WBC BldType Rh FBS HbA1c
BUN Crea 66 Na 136 K 4 Ca Amylase ALT AST
Alb Uric acid A/G TP Chole TSH FT4 FT3
PT % Act INR APTT CT BT LDH
RPR HBsAg HIV TRIG HDL LDL VLDL Mg
URINALYSIS:
ECG:
2D-ECHO: EF %
RADIOGRAPHS:
UTZ

MRI:

CONSULTANTS: DR. SROD/ AROD (DR LOPEZ) RESIDENTS: Dr BATOBALONOS

April 20, 2017 QMS-ORC-F62-0


ANESTHESIA POST-OP NOTES

IMMEDIATE POST-OP NOTES (before discharge from recovery room)

____________ NO COMPLICATIONS OF ANESTHESIA IMMEDIATELY APPARENT

____________ PATIENT HAS RECOVERED FROM IMMEDIATE EFFECTS OF


ANESTHESIA AND MAY BE TRANSFERRED TO WARD

____________ OTHERS

_______________________ M. D. __________________ __________


Signed Date Time

FOLLOW-UP POST-OP NOTES (After discharge from recovery room, before discharge from hospital)

__________ NO APPARENT ANESTHESIA COMPLICATIONS

__________ OTHERS

_______________________ M. D. __________________ __________


Signed Date Time

OPD Patient Screening Form

In the past two weeks did the patient have any of the following: YES NO
1. Respiratory symptoms
 
A. Cough
B. Shortness of breath  
C. Colds  
D. Throat pain  
E. Anosmia  
F. Other respiratory symptoms (headache, muscle and joint pains, diarrhea, lack of taste)  
2. Fever more than 38°C  
3. History of COVID-19 infection  
4. Household member diagnosed with COVID-19  
5. Travel or Residence in an area reporting local transmission of COVID-19  
6. Contact or exposure to someone with recent travel to an area with local transmission of COVID-19  

April 20, 2017 QMS-ORC-F62-0

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