[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-1-en-105":3,"doc-seo-285823-105":53,"doc-detail-285823-en":127},{"code":4,"msg":5,"data":6},0,"success",[7,14,19,24,29,34,39,44,49],{"id":8,"doc_module":9,"doc_module_name":10,"category_name":11,"show_sort_weight":12,"slug":13},11,1,"Template","Presentations",90,"presentations",{"id":15,"doc_module":9,"doc_module_name":10,"category_name":16,"show_sort_weight":17,"slug":18},12,"Resumes",80,"resumes",{"id":20,"doc_module":9,"doc_module_name":10,"category_name":21,"show_sort_weight":22,"slug":23},14,"Invoices",70,"invoices",{"id":25,"doc_module":9,"doc_module_name":10,"category_name":26,"show_sort_weight":27,"slug":28},15,"Posters",60,"posters",{"id":30,"doc_module":9,"doc_module_name":10,"category_name":31,"show_sort_weight":32,"slug":33},16,"Social Media",50,"social-media",{"id":35,"doc_module":9,"doc_module_name":10,"category_name":36,"show_sort_weight":37,"slug":38},17,"Forms",40,"forms",{"id":40,"doc_module":9,"doc_module_name":10,"category_name":41,"show_sort_weight":42,"slug":43},18,"Letters",30,"letters",{"id":45,"doc_module":9,"doc_module_name":10,"category_name":46,"show_sort_weight":47,"slug":48},21,"Paper Templates",5,"papers-templates",{"id":50,"doc_module":9,"doc_module_name":10,"category_name":51,"show_sort_weight":4,"slug":52},158,"General","general-158",{"code":4,"msg":54,"data":55},"ok",{"site_id":56,"language":57,"slug":58,"title":59,"keywords":60,"description":61,"schema_data":62,"social_meta":120,"head_meta":122,"extra_data":124,"updated_unix":126},105,"en","prmc-pre-op-clearance-form-surgical-preparation-document","PRMC Pre-Op Clearance Form - Surgical Preparation Document","","This document provides a standardized pre-operative clearance form designed for surgical coordination between surgeons and primary care physicians, cardiologists, or pulmonologists. It includes comprehensive sections for documenting patient demographics, planned surgical procedures, and surgery locations. The form features an extensive checklist for assessing medical conditions, such as coronary artery disease, valvular heart disease, and pulmonary hypertension, while facilitating the systematic review of necessary diagnostic tests including EKG, CBC, and cardiac reports. By requiring specific physician signatures, recommended treatment optimizations, and clear confirmation of surgical eligibility, the form serves as a critical communication bridge ensuring patient safety and standardized medical evaluation before any surgical intervention. The structured layout allows for efficient documentation of beta blockade information and ongoing cardiac health monitoring, making it an essential tool for clinical workflow management and pre-operative risk assessment in hospital and outpatient settings.",{"@graph":63,"@context":119},[64,80,102],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/prmc-pre-op-clearance-form-surgical-preparation-document/285823/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/prmc-pre-op-clearance-form-surgical-preparation-document/285823.png","ImageObject",442,249,{"name":88,"@type":89},"Putri","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-23","2026-09-17",true,{"@type":98,"interactionType":99,"userInteractionCount":101},"InteractionCounter",{"@type":100},"ViewAction",9,{"@type":103,"mainEntity":104},"FAQPage",[105,111,115],{"name":106,"@type":107,"acceptedAnswer":108},"What is the primary purpose of the PRMC Pre-Op Clearance Form?","Question",{"text":109,"@type":110},"The form serves to facilitate communication between the surgeon and a patient's medical providers (PCP, cardiologist, or pulmonologist) to ensure all necessary medical evaluations and tests are completed and reviewed before a scheduled surgery.","Answer",{"name":112,"@type":107,"acceptedAnswer":113},"Who is responsible for completing the section regarding medical conditions?",{"text":114,"@type":110},"The primary care physician, cardiologist, or pulmonologist is responsible for completing the medical condition assessment, attaching relevant cardiac reports, and confirming the patient's clearance for the procedure.",{"name":116,"@type":107,"acceptedAnswer":117},"What documentation should be attached along with this form when faxing it to the surgeon's office?",{"text":118,"@type":110},"Physicians must attach the most recent stress test, echocardiogram, and/or cardiac catheterization reports, along with any other requested diagnostic evaluations to ensure the surgeon has a complete clinical picture.","https://schema.org",{"og:url":78,"og:type":121,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":123,"canonical":78},"index,follow",{"doc_id":125,"site_id":56},285823,1790737597,{"code":4,"msg":5,"data":128},{"doc_id":125,"user_id":129,"nickname":88,"user_avatar":130,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":131,"file_id":132,"file_url":133,"file_type":134,"file_size":135,"view_count":101,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":9,"language":136,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":61,"update_tm":140,"read_time":4},962085571259,"https://ap-avatar.wpscdn.com/davatar_29158cc5080c5b710cf443261637dec0","PRMC PRE-OP CLEARANCE FORM  \nSURGEON INSTRUCTIONS:  \n1. Complete the section below  \n2. Fax this form to primary care physician/cardiologist/hospitalist –OR– give to patient to take to their medical physician  \nPt. Name:  \nDate of Birth:  \nSurgical Procedure:  \nDate Scheduled:  \nSurgeon Name:  \nSurgeon Fax \\#:  \nSurgery Location: [ ] main hospital  \n[ ] outpatient ASC  \nTests Ordered: [ ] CBC [ ] BMP [ ] HCG [ ] CXR [ ] EKG [ ] Other:  \n\n| PRIMARY CARE / CARDIOLOGIST / PULMONOLOGIST INSTRUCTIONS:\u003Cbr>1. Complete the section below (check all medical conditions that apply)\u003Cbr>2. Attach most recent stress test, echocardiogram, and/or cardiac cath reports\u003Cbr>3. Fax this form and test reports to the surgeon’s office (see surgeon’s fax \\# in section above)\u003Cbr>4. Also fax this form and test reports to the pre-op clinic at 258-7595\u003Cbr>5. Do not send this form back to surgeon or pre-op clinic until all pre-op tests/evaluations are complete and the results reviewed and found to be acceptable for surgery |\n| --- |\n| [ ] Coronary artery disease\u003Cbr>Revascularization procedures:\u003Cbr>Current ischemia risk: [ ] very low [ ] low [ ] moderate [ ] high [ ] CHF or cardiomyopathy or impaired LV function: most recent EF:   %[ ] Valvular heart disease:\u003Cbr>If aortic stenosis: Valve area:   cm2 Gradient:   mmHg [ ] Pulmonary hypertension: pulmonary artery pressure:   etiology:\u003Cbr>[ ] Cardiac arrhythmias:\u003Cbr>[ ] pacemaker [ ] AICD (please attach copy of patient ID card)[ ] COPD or emphysema or asthma: [ ] Sleep apnea\u003Cbr>[ ] Other medical conditions: [ ] PVD [ ] HTN [ ] Diabetes [ ] Other:\u003Cbr>RECOMMENDATION:  Comments:\u003Cbr>[ ] The patient is cleared for the planned surgical procedure [ ] All pre-op tests have been completed and results reviewed [ ] Pre-op beta blockade: drug, dosage, date started:\u003Cbr>[ ] The patients medical condition is optimized, no further pre-operative testing is necessary.\u003Cbr>Signature:   Date:  \u003Cbr>Printed Name:   Phone No:   |\n\nSPF 294-08","cbCaif3VS3D3MKHj","https://ap.wps.com/l/cbCaif3VS3D3MKHj","pdf",103576,"English","# Surgeon Instructions\n## Patient Information\n## Surgical Procedure Details\n## Test Orders\n# Physician Clearance Instructions\n## Medical Conditions Assessment\n## Pre-Operative Recommendation and Signature","[{\"question\":\"What is the primary purpose of the PRMC Pre-Op Clearance Form?\",\"answer\":\"The form serves to facilitate communication between the surgeon and a patient's medical providers (PCP, cardiologist, or pulmonologist) to ensure all necessary medical evaluations and tests are completed and reviewed before a scheduled surgery.\"},{\"question\":\"Who is responsible for completing the section regarding medical conditions?\",\"answer\":\"The primary care physician, cardiologist, or pulmonologist is responsible for completing the medical condition assessment, attaching relevant cardiac reports, and confirming the patient's clearance for the procedure.\"},{\"question\":\"What documentation should be attached along with this form when faxing it to the surgeon's office?\",\"answer\":\"Physicians must attach the most recent stress test, echocardiogram, and/or cardiac catheterization reports, along with any other requested diagnostic evaluations to ensure the surgeon has a complete clinical picture.\"}]","PRMC Pre-Op Clearance Form - Surgical Preparation Document | PDF",1789630360]