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PA preoperative assessment template

Use this for physician assistant preoperative visits where indication, medical risk factors, medication holds, labs/ECG, ASA-relevant status, and clear peri-operative instructions need a structured note.

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Template content

Copy or download, then paste into Wavo under My Templates.

Physician Assistant Preoperative Assessment

Procedure Planned
- Planned procedure, laterality, surgeon/service, and scheduled date.
- Indication and brief disease/injury context.

History Relevant to Anesthesia / Surgery
- Cardiac, pulmonary, bleeding, endocrine, renal, hepatic, OSA, GERD, prior anesthesia complications.
- Exercise tolerance / functional capacity as discussed.
- Medications (especially anticoagulants, antiplatelets, SGLT2i, GLP-1, steroids, insulin), allergies, and substance use.
- Last menstrual period / pregnancy status if applicable.

Exam
- Vital signs, airway-relevant exam (Mallampati if performed), cardiopulmonary exam, and surgical-site findings as relevant.

Data Reviewed
- Labs, ECG, imaging, cardiac testing, and outside records reviewed for clearance.
- Pending items required before surgery.

Risk Assessment / Impression
- Perioperative risk considerations and optimization status (optimized / needs further workup / defer).
- ASA class if assigned by protocol/clinician workflow.

Plan / Instructions
- Medication holds and restart plan (anticoagulation bridging if applicable).
- NPO / carbohydrate-loading / glucose management instructions.
- Additional testing or specialty clearance requested.
- Arrival time, consent status if obtained, and who to call with changes in health status.
- Discussion with collaborating physician / surgeon if escalation needed.

When to use this template

What makes the structure useful, and which visits it fits best.

Why this template works

Structural advantages for real documentation

Best for

Visit types and clinicians who use this format

  • Separates surgical indication from medical optimization and clearance elements.
  • Prompts anticoagulation, diabetes, and cardiac risk checkpoints common to pre-op clinics.
  • Documents NPO, med holds, and contingency plans patients actually need.
  • Works for PA-run pre-op clinics and day-of surgical readiness notes.
  • 1PA preoperative clinic assessments
  • 2Day-of pre-op readiness documentation
  • 3Surgical co-management pre-op visits

Example output shape

Illustrative excerpt of how a visit can land in this structure. Not a real patient record—review and edit every note before signing.

Procedure Planned
Right laparoscopic inguinal hernia repair with Dr. Patel on 8/12. Indication: symptomatic reducible right inguinal hernia limiting work.

History
56M; HTN on amlodipine; no CAD, CHF, COPD, or prior anesthesia issues. Walks 2 flights without chest pain. Takes aspirin 81 mg for primary prevention—will hold per surgeon. No anticoagulants. NKDA. Former smoker quit 10 years; rare alcohol. Good exercise tolerance.

Exam
BP 128/78, HR 72, SpO2 98% RA. Mallampati II; lungs clear; heart regular; reducible right inguinal hernia, nontender; no skin infection at site.

Data
CBC/CMP within 30 days normal; ECG sinus rhythm. No further cardiac testing indicated based on low risk + good functional capacity.

Impression
Optimized for elective outpatient hernia repair; low perioperative risk from PA pre-op assessment standpoint.

Plan
Hold aspirin 5 days pre-op; restart 24h post-op if hemostasis OK per surgeon. NPO after midnight; take amlodipine AM of surgery with sip of water. Arrive 2 hours pre-op. Call for fever, URI, or uncontrolled BP. Consent to be completed in surgery clinic; attending surgeon aware.

How Wavo automates this

What the product actually does with your template.

1. Add the template

Paste this content into My Templates, or start from a specialty-generated template and edit the sections.

2. Record or dictate

Capture the encounter with ambient recording or dictation. Wavo structures the note using your template.

3. Review and sign

Edit with Smart Transform if needed, then export or copy into your EHR. You stay responsible for the final note.

Put this template to work on your next visit

Start free, paste the template, and see how Wavo documents in your structure.

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