Risk Management

Preoperative History and Physical Examinations

Anne M. Menke, RN, PhD, OMIC Risk Manager

Digest, V24 N1 2014

As the lead article explains, recent guidelines have helped clarify that patients cannot be “cleared” for surgery and that the purpose of the preoperative evaluation is to identify risks that need to be managed during the perioperative period. This Hotline article will address common questions about performing preoperative history and physical exams (H&Ps).

Q How extensive does the H&P need to be?

A Ophthalmic surgery has been deemed to be low risk, so eye surgeons are screening for medical conditions that could adversely affect the patient, especially those that involve the cardiovascular and respiratory systems and need to be mitigated before or monitored during surgery.1 The history includes a review of systems and of medications.

During the exam, the surgeon needs to review the vital signs and listen to the patient’s heart and lungs to screen for conditions that might warrant further evaluation by the patient’s primary care physician and/or anesthesia provider. Some ophthalmologists ask the patient’s PCP to send the results of the most recent complete physical exam to use as a baseline for the H&P, while others consult with the PCP only if their own H&P raises concerns.

Ophthalmologists will need to use professional judgment in deciding when to consult with other physicians or refer the patient to a PCP. Many patients undergoing eye surgery are older and most have medical conditions. Nonetheless, patients who are reliable historians and are reportedly stable may not need to be referred unless the ophthalmologist determines that the medical regimen may need to be changed to reduce the risk of perioperative complications (see the lead article for a discussion on anticoagulants).

Q Are there other measures of a patient’s ability to withstand surgery that ophthalmologists should consider assessing?

A Yes. Eye surgeons can evaluate their patient’s functional capacity, a measure based upon the patient’s reported ability to perform a spectrum of common daily tasks ranging from self-care, slow walking, light housework, stair climbing, and rapid walking, to heavy housework, moderate recreational activities, and strenuous sports. Studies cited in the guidelines indicate that functional capacity correlates well with maximum oxygen uptake by treadmill testing.2 Patients with very limited functional capacity may have undiagnosed or undertreated cardiac, medical, or pulmonary conditions and may need to be evaluated by their PCP. In any event, information about the patient’s functional capacity can be included in the H&P report that is sent to the surgery center or hospital.

Q May I delegate the preoperative H&P to licensed staff, such as registered nurses, nurse practitioners, and physician assistants?

A Yes, the scope of practice and skill set of these providers allows them to perform these exams. If the licensed person conducting the exam is your employee, you will likely have vicarious liability for his or her care and are expected to supervise it. Registered nurses will require the most guidance and supervision.

You will need to develop a written protocol that provides guidance on the questions to ask during the review of systems and the extent of the exam. You are responsible for reviewing the completed H&P and determining the patient’s ability to proceed with surgery. Follow up on positive H&P findings, determine the need for consultations or referrals, date and sign the document, and communicate the results to the anesthesia provider. Address any concerns raised by the H&P directly with the patient as well.

Nurse practitioners (NPs) and physician assistants (PAs) routinely conduct comprehensive H&Ps, so they will not need guidance in how to perform them. They tend to be employees of a surgery center rather than of an ophthalmologist and may be performing the preoperative H&P or the reassessment on the day of surgery. If you are asked to sign a report prepared by an NP or PA who is not your employee, your signature acknowledges that the patient’s medical condition has been evaluated, but does not imply that you are attesting to the accuracy or thoroughness of the examination in question. Once such an NP or PA has completed the H&P or reassessment, read it and write “Patient (re)assessed for surgery by ___________ NP/PA” (include the provider’s name and title).

1. Zambouri A. “Preoperative Evaluation and Preparation for Anesthesia and Surgery.” Hippokratia. 2007 Jan-Mar; 11(1): 13–21.
2. ACC/AHA “Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery.” Circulation. 2007; 116:e418-e500.

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