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At some point before surgery a health care provider conducts a preoperative assessment to verify that a person is fit and ready for the surgery. [1] [2] For surgeries in which a person receives either general or local anesthesia, this assessment may be done either by a doctor or a nurse trained to do the assessment. [2]
Preanesthetic assessment (also called preanesthesia evaluation, pre-anesthesia checkup (PAC) or simply preanesthesia) is a medical check-up and laboratory investigations done by an anesthesia provider or a registered nurse before an operation, to assess the patient's physical condition and any other medical problems or diseases the patient might have. [1]
Pre-hospital emergency medicine (abbreviated PHEM), also referred to as pre-hospital care, immediate care, or emergency medical services medicine (abbreviated EMS medicine), is a medical subspecialty which focuses on caring for seriously ill or injured patients before they reach hospital, and during emergency transfer to hospital or between hospitals.
An admission note is part of a medical record that documents the patient's status (including history and physical examination findings), reasons why the patient is being admitted for inpatient care to a hospital or other facility, and the initial instructions for that patient's care. [1]
It is used for alert (conscious) people, but often much of this information can also be obtained from the family or friend of an unresponsive person. In the case of severe trauma, this portion of the assessment is less important. A derivative of SAMPLE history is AMPLE history which places a greater emphasis on a person's medical history. [2]
The prior authorization, or pre-certification process, requires healthcare providers to get coverage approval for certain non-emergency procedures. Cigna removes pre-authorization requirement for ...
The operative report includes preoperative and postoperative diagnoses, patient condition after surgery, all medications used in association with the procedure, pertinent medical history (Hx), physical examination (PE), consent forms, surgeon′s orders, and identifies the anesthetist and anesthesia used. [2] [3]
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