Brief Pre-op Note

Date & Time

Brief History

Pre-operative Diagnosis

Planned Procedure

Brief Physical Exam

Lab Data

Type & Screen or Cross Match (# units)

Chest X-ray

ECG

Consent

1. Includes documentation of a discussion between the attending surgeon and the patient of:

    

1. the potential risks and benefits of the procedure,

    

2. the potential complications of the procedure,

    

3. the alternatives to the procedure,

    

4. and a statement that all of the patient’s questions have been answered.

    

2. A statement that the patient agrees to the procedure.

    

3. The consent has been signed and witnessed.

    

4. The documentation of the discussion by the attending (a – d, above) may be at another place in the chart or, perhaps, in the office records.