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Preparing for Surgery? Here's Why a Complete History and Physical is Essential!

Updated: Jul 31, 2023

Anyone who’s ever had surgery knows that there’s a lot of preparation that goes into the procedure. But have you ever stopped to think about why a complete history and physical is so important before going under the knife?


operating room with staff talking about the case

In this article, we’ll explore the importance of having a complete history and physical before surgery. We’ll discuss Medicare requirements, CMS guidelines, how to prepare for a complete history and physical, the types of tests required before surgery, and the role of the operating room staff in the procedure. We’ll also cover the importance of communication between the surgeon and patient, and why a complete history and physical is essential before surgery.




What is a history and physical?

A history and physical (H&P) is a comprehensive evaluation of a person’s medical history and current health status. It is performed by a healthcare provider and typically includes a review of the patient’s medical history, physical exam, and laboratory tests. The purpose of the H&P is to assess the patient’s overall health, identify any potential risks associated with the upcoming surgery, and ensure the patient is a suitable candidate for the procedure.


The H&P is not only important for the patient but also for the healthcare provider. It provides the healthcare provider with important information that can help them in pre-operative planning and decision-making.





Why is a complete history and physical important before surgery?

Having a complete H&P before surgery is essential for a number of reasons. First, it provides a comprehensive overview of the patient’s health and any existing medical conditions that could affect the outcome of the surgery. This information is important for the surgeon to have before they make any decisions regarding the procedure.


Second, a complete H&P helps to identify any potential risks associated with the surgery. This includes any allergies the patient may have, any medications they’re taking, and any preexisting medical conditions that could complicate the procedure. A complete H&P allows the healthcare provider to make informed decisions about the safety of the procedure and potential risks.


Third, a complete H&P can help to identify any underlying medical conditions that could increase the risk of complications, such as high blood pressure or diabetes. This can be especially important for surgeries that involve anesthesia, as these conditions can increase the risk of serious complications.


Finally, a complete H&P can provide the surgeon with valuable information about the patient’s overall health and medical history, which can help them in their decision-making process. This can include information about the patient’s age, lifestyle, and any preexisting conditions that could affect the outcome of the procedure.





Medicare requirements for a complete history and physical

The Centers for Medicare and Medicaid Services (CMS) has outlined specific requirements for a complete H&P before surgery. According to the CMS, a complete H&P must include the following elements:


A review of the patient’s medical history and current health status

An assessment of the patient’s fitness for the surgery

A description of any pre-existing medical conditions

A description of any medications and allergies

A review of the patient’s laboratory and diagnostic tests

A discussion of any potential risks associated with the surgery

The CMS also requires that the H&P be completed by a healthcare provider who is qualified to perform the procedure. This includes a physician, nurse practitioner, or physician assistant.





CMS guidelines for the history and physical

In addition to the Medicare requirements, the CMS has issued additional guidelines for the completion of the H&P. These guidelines include the following:


  • The H&P must be completed within 30 days of the scheduled surgery

  • The H&P must be completed by a healthcare provider who is qualified to perform the procedure

  • The H&P must include an assessment of the patient’s fitness for the surgery

  • The H&P must include a review of the patient’s medical history and current health status

  • The H&P must include a description of any pre-existing conditions, medications, and allergies

  • The H&P must include a review of the patient’s laboratory and diagnostic tests

These guidelines are in place to ensure that the H&P is complete and accurate, and that the patient is a suitable candidate for the procedure.





How to prepare for a complete history and physical

Preparing for a complete H&P can seem overwhelming, but it doesn’t have to be. Here are a few tips on how to prepare for a complete H&P:


Make a list of all medications you’re taking, including any over-the-counter medications, vitamins, and supplements.

Make a list of any allergies you have, including any food allergies or drug allergies.

Make a list of any medical conditions you have, including any chronic conditions or past surgeries.

Make a list of any laboratory or diagnostic tests you’ve had in the past.

Bring a copy of your medical records, including any past surgeries or medical conditions.

Bring a list of any questions you have for the healthcare provider.

By taking the time to prepare for the H&P, you can ensure that the healthcare provider has all the information they need to make an informed decision about your surgery.







Types of tests required before surgery

In addition to the H&P, there are a number of tests that may be required before surgery. These tests may include blood tests, urine tests, imaging tests (such as X-rays or CT scans), and electrocardiograms (ECGs). The purpose of these tests is to identify any potential risks associated with the surgery and to make sure the patient is a suitable candidate for the procedure.


Your healthcare provider will determine which tests are necessary based on your medical history, current health status, and the type of surgery you are scheduled to have. It’s important to discuss any tests you may need with your healthcare provider before the surgery to ensure you have a safe and successful procedure.




The role of the operating room staff in the history and physical

The operating room staff plays an important role in the H&P process. They are responsible for ensuring that the patient is medically cleared for the surgery and that all necessary tests have been completed. The operating room staff will also ensure that the patient’s medical history and current health status are accurately documented.


The operating room staff will also monitor the patient’s vital signs throughout the procedure and ensure that any necessary medications or treatments are administered.




The importance of communication between the surgeon and patient

Having a complete H&P before surgery is essential, but it’s also important to have open communication between the surgeon and patient. It’s important for the patient to discuss any questions or concerns they may have with the surgeon, and for the surgeon to explain any potential risks or complications associated with the procedure.


Having open communication between the surgeon and patient ensures that the patient is fully informed and that the surgeon is aware of any potential risks or complications associated with the procedure.




The importance of a complete history and physical before surgery

A complete H&P is essential before any surgery. It provides the healthcare provider with important information about the patient’s overall health and medical history, which can help them in their decision-making process. It also helps to identify any potential risks associated with the surgery and makes sure the patient is a suitable candidate for the procedure.


Finally, having open communication between the surgeon and patient is essential for a successful procedure. The patient should always feel comfortable asking questions and expressing any concerns they may have.





Conclusion

Having a complete history and physical before surgery is essential for a safe and successful procedure. It provides the healthcare provider with important information about the patient’s medical history and current health status, which can help them make informed decisions about the procedure. It also helps to identify any potential risks associated with the surgery and makes sure the patient is a suitable candidate for the procedure.


By following Medicare and CMS guidelines and taking the time to prepare for the H&P, you can ensure that you have a safe and successful surgery.

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