Guideline text:
(Rev. 200, Issued: 02-21-20; Effective: 02-21-20, Implementation: 02-21-20)

[The bylaws must:]

§482.22(c)(5) - Include a requirement that  --

- (ii)  An updated examination of the patient, including any changes in the patient's condition, be completed and documented within 24 hours after admission or registration, but prior to surgery or a procedure requiring anesthesia services, when the medical history and physical examination are completed within 30 days before admission or registration, and except as provided under paragraph (c)(5)(iii) of this section.  The updated examination of the patient, including any changes in the patient's condition, must be completed and documented by a physician (as defined in section 1861(r) of the Act), an oral and maxillofacial surgeon, or other qualified licensed individual in accordance with State law and hospital policy.

## Interpretive Guidelines §482.22(c)(5)(ii)

The Medical Staff bylaws must include a requirement that when a medical history and physical examination has been completed within 30 days before admission or registration, an updated medical record entry must be completed and documented in the patient's medical record within 24 hours after admission or registration, except when the patient is receiving an outpatient surgical or procedural services and when the medical staff has developed and maintained a policy (in accordance with §482.22(c)(5)(v)) that identifies specific patients that do not require a comprehensive medical H&amp;P, or any update to it, prior to the outpatient surgery or procedure.

The examination must be conducted by a licensed practitioner who is credentialed and privileged by the hospital's medical staff to perform an H&amp;P.  In all cases, the update must take place prior to surgery or a procedure requiring anesthesia services.  The update note must document an examination for any changes in the patient's condition since the patient's H&amp;P was performed that might be significant for the planned course of treatment.  The physician or qualified licensed individual uses his/her clinical judgment, based upon his/her assessment of the patient's condition and co-morbidities, if any, in relation to the patient's planned course of treatment to decide the extent of the update assessment needed as well as the information to be included in the update note in the patient's medical record.

If, upon examination, the licensed practitioner finds no change in the patient's condition since the H&amp;P was completed, he/she may indicate in the patient's medical record that the H&amp;P was reviewed, the patient was examined, and that "no change" has occurred in the patient's condition since the H&amp;P was completed (71 FR 68676).  Any changes in the patient's condition must be documented by the practitioner in the update note and placed in the patient's medical record within 24 hours of admission or registration, but prior to surgery or a procedure requirement anesthesia services.  Additionally, if the practitioner finds that the H&amp;P done before admission is incomplete, inaccurate, or otherwise unacceptable, the practitioner reviewing the H&amp;P, examining the patient, and completing the update may disregard the existing H&amp;P, and conduct and document in the medical record a new H&amp;P within 24 hours after admission or registration, but prior to surgery or a procedure requiring anesthesia.

## Survey Procedures §482.22(c)(5)(ii)

- Review the medical staff bylaws to determine whether they include provisions requiring that, when the medical history and physical examination was completed within 30 days before admission or registration, an updated medical record entry documenting an examination for changes in the patient's condition was completed and documented in the patient's medical record within 24 hours after admission or registration.
- Determine whether the bylaws require that, in all cases involving surgery or a procedure requiring anesthesia services, the update to the H&amp;P must be completed and documented prior to the surgery or procedure.
- In the sample of medical records selected for review, look for cases where the medical history and physical examination was completed within 30 days before admission or registration.  Verify that an updated medical record entry documenting an examination for any changes in the patient's condition was completed and documented in the patient's medical record within 24 hours after admission or registration.  Verify that in all cases involving surgery or a procedure requiring anesthesia services, the update was completed and documented prior to the surgery or procedure.

Structured rule (JSON):
{"intent_tags": ["safety", "quality", "compliance"], "logic_config": {"exceptions": [{"id": "c(5)(iii)", "type": "reference"}, {"condition": "medical staff policy identifies specific patients not requiring H&P or update", "type": "outpatient_procedure"}], "required_artifact": {"documentation_content": "changes in patient's condition", "performer_qualifications": ["Physician", "Oral and Maxillofacial Surgeon", "Other qualified licensed individual"], "temporal_constraints": [{"max_delay_hours": 24, "relative_to": "Admission or Registration"}, {"must_precede": "Surgery or procedure requiring anesthesia services"}], "type": "Updated Examination"}, "trigger_assertion": {"conditions": [{"event": "Medical History and Physical Examination", "time_relative_to_admission": "within 30 days prior"}, {"event": "Admission or Registration"}], "type": "AND"}}, "rule_type": "conditional_existence", "scope_tags": ["clinical", "facility", "legal"]}