Wiki Pre-op Clearance for Surgery

dsproveri

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When auditing a pre-op consultation, how are you reaching your four HPI elements? Can you count the elements which caused the need for surgery? (i.e. pt became dizzy upon standing, fell and now has severe pain in her left hip and shoulder) even though your MD is not the surgeon, OR must the PMD document the status of any other medical conditions (i.e. HTN, DM, osteoporosis, etc.)? My physicians are stating their other health issues but not stating the status of them. Help please. Thanks!
 
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