brevaPre-operative evaluation
Encounter
Patient name: [ ] Date of birth: [ ] Date and time of encounter: [ ] Clinician: [ ]
Planned procedure
Procedure, date and surgeon or facility: [ ] Anesthesia type if known: [ ] Reason for referral and questions asked by the surgical team: [ ]
History
Medical and surgical history: [ ] Prior anesthesia problems, personal or family, as reported: [ ] Functional capacity as reported: [ ] Cardiac, pulmonary and bleeding history as reported: [ ] Medications, including anticoagulants and supplements, and allergies: [ ]
Evaluation
Vitals measured today, with units: [ ] Examination performed and findings: [ ] Tests ordered or reviewed, with dates and results: [ ] Risk tool used and result, if any: [ ]
Assessment and recommendations
Risk assessment and reasoning: [ ] Medication instructions before and after the procedure: [ ] Recommendations and conditions for the surgical team: [ ] How and when the recommendation was sent: [ ]