This chapter will help you complete the PreOp-Worksheet so you can take it with you to the hospital on your day of surgery. Before you attempt to fill out the worksheet, you should have several things in your possession. Gather up all of the medications you take on a regular basis and put them on a table. Include in this group any over-the-counter medications you take more than weekly. You should also have a phone book to look up the address and telephone number of any physician who has treated you within the past year or two. If you keep a file of old medical records, gather them together now as well, for you will need to know the dates of your most recent examinations and hospitalizations. Find all of your insurance cards now, and remember to bring them to the hospital with you. This is especially important for people who are covered under more than one policy, as you want to make sure the bills are forwarded to the proper company as soon as possible. If you have any legal documents pertaining to your medical care, bring them with you to the hospital, this includes a copy of your living will and durable power of attorney (if you have either). Finally, I suggest you fill the worksheet out with a pencil, as you are likely to make additions, corrections, and deletions as you remember details over time.
Section 1: Demographic Information
This section is easy to complete. The information is useful primarily to your physicians and nursing staff. It will enable them to contact your home or a member of your family, should the need arise. Remember that you should designate a friend or family member to be your primary contact person. This is the person who will receive all important phone calls from the hospital, and who will be responsible for informing the remainder of your family and friends of your condition. A common problem in hospitals these days is the dissemination of information to patient’s families. Legally, health care providers are bound to not release specific medical information, particularly over the phone. Many family members do not understand this and become irate when denied access to information to which they feel entitled. Before your operation, make it clear to everyone whom to call for daily updates or in the event of an emergency. Remember, the more time your doctor or nurse spends talking to family members, the less time they will have to take care of you. You should also have a discussion with your primary contact about your wishes for life-saving and/or life-prolonging therapy in the event you suffer a catastrophic complication. This is especially true if you have strong feelings about the use of mechanical ventilation, tube feeding, and nursing home care.
Section 2: Medical History
It is critically important that your surgeon have access to your past medical record and be able to contact physicians who are actively caring for you. In many small communities, this is easily accomplished, as only a small number of physicians work at any given hospital or clinic. In larger communities, not all physicians know one another, and you would not want this lack of familiarity to adversely impact your care. It may be time consuming to find all of the addresses and phone numbers of your physicians, but would you rather spend the time now, or have your surgeon waste time in an emergency situation?
When recording the medications you take, be sure to copy the name exactly from the pill bottle. You should also find the dosage of the medication written on the bottle, as well as the number of pills and the number of times you take the pill(s) daily. All of this information is important so you can resume your regular medication schedule as soon as possible after surgery. If you have been asked to stop taking a medication before your operation, include it on this list anyway, and make a note of the last time you took that drug. The question regarding drug allergies is equally important. Simply writing a list of medications you may have had allergic reactions to is not enough. You should also note what type of adverse reaction you had to the drug and when you stopped taking the drug. Today, there are many drug families that have overlapping effects and overlapping allergic reactions It will be important for your surgeon to know how likely it is that you will have a bad reaction to a class or family of medications. If you have been on antibiotics in the past year, you should include this information on the worksheet. It is important to know exactly what antibiotic you were taking and why it was prescribed. If you do not remember, call your doctor’s office and ask to check your medical records for this information.
When listing your past medical and surgical history, it is important to list not only the conditions for which you have been treated but also when those conditions were diagnosed, and by whom. If you have trouble remembering the details of your specific medical conditions or operations, call the office of the physician who cared for you and ask for this information. This will be especially helpful in the case of previous surgeries. If possible, ask for copies of old operative reports and hospital discharge summaries. Some offices may refuse to send these documents directly to you, but they may be willing to forward them to your current surgeon. Finally, if you have been admitted to any hospital in the past several years, it may become necessary to contact the medical records department of that hospital for additional information. By providing the hospital name, location, and phone number, you can expedite this process and increase the likelihood that all of the necessary information is available to your surgeon.
Section 3: Social History
As I have stressed earlier in the book, it is imperative that your surgeon know the details of your social habits. There is no substitute for honesty in this section, and you could put yourself in serious jeopardy by failing to report your use of tobacco and alcohol products. Similarly, the use of narcotic pain medications or other recreational drug use should be noted. Your surgeon is obligated by law not to share this information with anyone, so it should not worry you. If you have a few skeletons in your closet, most other people do too.
Section 4: Family History
One of the best indicators of possible problems with anesthesia or surgery is a family history. Diseases such as coagulation disorders or sensitivity to medications can sometimes run in families. If you are unsure about your family’s history regarding surgery, contact one of your elder relatives. Most families have one or two senior members who will be able to tell you at least some of the details of operations on other family members.
Section 5: Legal Documents
This section requests that you list any important legal documents that may assist in rendering your medical care. Remember, if you have a living will or durable power of attorney for health care, you should bring a copy of the document with you to the hospital. Your primary contact should be the person to whom you have granted power of attorney. If you have a family lawyer, you should also include his or her name and phone number here as well. If you have any feelings regarding final wishes or organ donation, make them known.