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Houma Outpatient Surgery Center AAAHC ACCREDITED 3717 Houma Blvd 3rd Floor P 504 456 1515 Metairie La. 70006 F 504 454 3810 Medical Clearance for Surgery/Anesthesia Patient Date of Surgery/Anesthesia Surgeon recommending patient for medical clearance Proposed surgical procedure anesthesia Indications for Medical Clearance Labs/Tests/Diagnostics needed Patient is cleared for proposed surgical procedure anesthesia Yes No Recommendations for surgery/anesthesia Comments Examining Physician...
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How to fill out surgical clearance form
How to fill out surgical clearance form:
01
Start by providing your personal information, including your name, date of birth, address, and contact information.
02
Next, disclose your medical history and any pre-existing conditions that may be relevant to the surgery. This includes any chronic illnesses, previous surgeries, or allergies to medications.
03
Indicate any current medications you are taking, including prescription drugs, over-the-counter medications, and supplements. Be sure to include the dosage and frequency of use.
04
Provide details about your lifestyle habits, such as smoking, alcohol consumption, or recreational drug use. This information helps the medical team assess potential risks during and after the procedure.
05
Mention any known or suspected pregnancy, as this may influence anesthesia and medication choices.
06
Specify any previous adverse reactions to anesthesia or any other complications experienced during previous surgeries.
07
If applicable, include any relevant laboratory test results or imaging studies that have been conducted recently.
08
Lastly, sign and date the form to indicate that the information provided is accurate and complete.
Who needs a surgical clearance form:
01
Patients who are scheduled to undergo a surgical procedure typically require a surgical clearance form. This ensures that the medical team is aware of their medical history and any potential risks associated with the surgery.
02
The form is often necessary for individuals who have pre-existing medical conditions, such as heart disease, diabetes, or high blood pressure, as these conditions may increase the risk of complications during surgery.
03
Patients who are taking medications that may interact with anesthesia or other medications administered during the surgery may also require a surgical clearance form to assess the potential risks and make necessary adjustments.
04
Additionally, individuals with a history of allergies or adverse reactions to anesthesia may be required to complete a surgical clearance form to ensure appropriate measures are taken to minimize potential complications.
Video instructions and help with filling out and completing surgical clearance form
Instructions and Help about surgical clearance template form
Music welcome to Florida hospitals patient education video the purpose of this video is to prepare you or your loved one for abdominal surgery as your safety and well-being our priority the information in this video will guide you from the planning of your surgery through your recovery in addition to this video your surgeon will provide information regarding the preparing for your surgery class please remember any questions related to your surgeries should be directed to your surgeon preparing for surgeries start to your surgeon's office you can expect to get the following details type and name of surgery you'll be having dates time and location of surgery possible risks or complications anticipated time in the hospital after surgery alternative treatment options any changes to your blood thinners or anticoagulants any medical clearance you may need readmission testing dates and location dates and times for preparing for your surgery class in addition you'll be signing your surgery consent form Music pre-admission testing involves completing the hospital registration process having tests and blood work drawn completing a personal health history review of any medication or supplements that you're taking verification of existing advance directives or living wills receiving preoperative instructions such as diet and bathing guidelines verifying the date and time of surgery and review of parking and surgery location you'll also receive a folder of information and chlorhexidine gluconate soap also known as CH g we'll go over the CH G bathing process later in the video Music here are some suggestions on things to bring to the hospital paperwork received at the readmission testing appointment ID and insurance card a list of your current medications and a toothbrush comb or brush and non-skid slippers we would suggest leaving the following at home your wallet or purse cash and credit cards jewelry and medications unless your surgeon told you otherwise if you have any additional questions about what to bring please contact your surgeon's office we suggest keeping all valuables at home unless you have someone that can keep them secured during your surgery diet prior to surgery is important especially the week leading up to surgery we recommend you follow a healthy diet rich and fruits and vegetables we suggest that you avoid alcohol completely and limit your red meat intake you'll need to stop eating solid foods after midnight the night before surgery your surgeon will advise you on consuming liquids and if there are any routine medicines you can take on the morning of your surgery if you're taking aspirin ibuprofen or are on any blood thinners please follow the instructions given by your surgeon as these may be stopped prior to your surgery Music one of the items that you'll receive in readmission testing is a bottle of chlorhexidine gluconate or CH G soap this soap helps lower the number of germs on your skin and will help prevent infections during and...
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Who is required to file surgical clearance form?
Patients who are scheduled for surgery must file a surgical clearance form. The form should be completed and signed by the patient's primary care physician.
How to fill out surgical clearance form?
1. Begin by filling in your personal information including your name, address, phone number, and date of birth.
2. Provide information about your medical history, including any existing medical conditions, recent surgeries, and any medications you are currently taking.
3. List any allergies you have or any medications that you are unable to take.
4. Provide details about any recent illnesses, such as the date of onset, symptoms, and treatments received.
5. Describe any tests or procedures you have had or are scheduled to have in the near future.
6. List any questions or concerns you have about the upcoming surgery.
7. Have your physician or surgeon sign the form to confirm that they have cleared you for surgery.
What is the purpose of surgical clearance form?
A surgical clearance form is used to determine a patient's eligibility for surgery. It is used to assess the patient's overall medical condition, to document any existing medical conditions that may affect the outcome of the surgery, and to verify that the patient is healthy enough for the procedure. The form also helps to identify any potential risk factors that may be present.
When is the deadline to file surgical clearance form in 2023?
The deadline to file surgical clearance forms in 2023 is dependent on the individual's healthcare provider and the specific surgery. It is best to contact the healthcare provider to get a specific timeline for filing any necessary paperwork.
What is surgical clearance form?
A surgical clearance form is a document that is usually filled out by a physician or a healthcare professional to assess a patient's overall health and fitness for a surgical procedure. The form typically includes medical history, current medications, and any pre-existing conditions that may affect the patient's ability to undergo surgery. It is used to determine if there are any potential risks or contraindications for the planned surgical intervention and to ensure that the patient is in an optimal state for the procedure. The surgical clearance form helps to ensure patient safety and allows the surgical team to make informed decisions about the patient's care.
What information must be reported on surgical clearance form?
The specific information required on a surgical clearance form may vary depending on the medical facility or surgeon. However, some common information that is typically requested includes:
1. Personal information: Name, date of birth, contact details, and any relevant identification numbers.
2. Medical history: This includes information about any existing medical conditions, surgeries, or past hospitalizations. It may also request details on any allergies, medications, or treatments that the patient is currently undergoing.
3. Previous surgical history: This section will ask about any previous surgeries, including when and where they were performed, as well as any complications or adverse reactions experienced.
4. Medication list: The patient is typically required to provide a comprehensive list of all medications they are currently taking, including prescription drugs, over-the-counter medications, and herbal supplements.
5. Family medical history: Some surgical clearance forms may also ask for information on the patient's family medical history, primarily focusing on any familial conditions or genetic diseases that may increase the risk of complications during surgery.
6. Current health status: The form may ask for general information regarding the patient's overall health, including current symptoms, recent illnesses, or any changes in their medical condition.
7. Diagnostic tests and results: This section will typically require the patient to provide details on any recent diagnostic tests, such as blood work, imaging scans, or electrocardiograms (ECG/EKG).
8. Risk assessment: Some surgical clearance forms may have a specific section dedicated to assessing the patient's risk for surgical complications, including their physical fitness, smoking status, alcohol or drug use, and any relevant lifestyle factors.
9. Consent and acknowledgment: The patient is often required to read and sign a consent form, acknowledging that they understand the potential risks and benefits of undergoing surgery and agree to proceed with the procedure.
It's important to note that each surgeon or medical facility may have specific requirements for surgical clearance forms, so it is best to consult the respective surgeon's office or healthcare provider to obtain the correct form and ensure all necessary information is included.
What is the penalty for the late filing of surgical clearance form?
The penalty for the late filing of a surgical clearance form can vary depending on the specific guidelines and policies of the organization or institution requiring the form. In some cases, there may be no penalty at all, while in others, a late fee or additional administrative charge may be applied. It is best to consult the relevant authority or organization for specific information on the penalties associated with late filing of a surgical clearance form.
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