What is required in a medical record prior to a procedure?

A History and Physical examination is a critical component that must be documented in a medical record prior to a procedure. This assessment involves a thorough review of the patient's medical history and a physical examination that helps to establish a baseline for the patient's current health status. It is essential for evaluating any potential risks associated with the procedure and for ensuring that the healthcare team is fully informed about the patient's health background.

Additionally, this documentation supports informed clinical decision-making and helps in planning the procedure safely, determining the appropriate anesthesia, and understanding any comorbidities that might influence the patient's care. While other elements like a signed consent form and a list of allergies are important for patient safety and legal compliance, the History and Physical examination is fundamental to patient assessment and preparation for the procedure itself.