History and Physical Joint Commission Medicare Conditions of Participation Surgical H&P must be done within 30 days prior to procedure and patient reassessed the day of surgery if it is a surgical emergency, procedure may be performed without an H&P if the surgeon documents pre-op diagnosis, pertinent physical findings and exam of heart and lungs prior to the induction of anesthesia H&Ps may be completed by a physician licensed to practice in NC but not a member of the medical staff; however the update prior to surgery must be completed by a member of the CVMC Medical Staff H&P Update: : An update must be completed, by a member of the medical immediately prior to a procedure requiring anesthesia indicating that the H&P was reviewed, the patient examined, and “no change” has occurred since H&P completion OR document any changes in patient condition prior to procedure requiring anesthesia. If the Same Day Surgery patient converts to inpatient status and the H&P of record was completed by a dentist or podiatrist, a complete History and Physical must be completed by an MD or DO. Dictated or handwritten Physician’s Progress Notes Physician’s office notes Transcribed report Chief Complaint History of Present Illness Relevant Past, Social, and Family Histories Review of Relevant Systems Physical Exam of all pertinent systems (minimum mandatory requirement of heart and lung exam) to include vital signs, Admitting/Provisional Diagnosis and Impression Treatment Plan and documentation of discussion of reasons for any limited treatment plan and patient and/or family informed of the plan MD, DO, oral surgeon, dentist, or podiatrist Resident PA NP PA, NP and Medical Students Scribe** Supervising physician must co-sign all H&Ps performed and documented by a resident. For PA, NP and Medical Students, H&Ps must be at the time of entry by the supervising provider. For Scribes, H&Ps must be authenticated at the time of the by the supervising provider and prior to leaving the patient unit. NONOPERATIVE INVASIVE PROCEDURES (i.e. CARDIAC CATH, TEE, STEROID INJECTIONS, MYELOGRAM, ANGIOPLASTY, etc., as defined in PC-38) History and Physical Joint Commission Non-operative invasive procedure H&Ps must be done within 30 days prior and the Dictated or handwritten Physician’s Progress Notes Chief Complaint History of Present Illness Relevant Past, Social, and Family Histories MD, DO, oral surgeon, Supervising LIP must co-sign all H&Ps performed and
update prior to surgery must be completed by a member of the CVMC Medical Staff H&P Update: An update must be completed, by a member of the medical staff, immediately prior to a procedure requiring anesthesia indicating that the H&P was reviewed, the patient examined, and “no change” has occurred since H&P completion OR document any changes in patient condition prior to procedure requiring anesthesia. If the Observation patient converts to inpatient status and the H&P of record was completed by a dentist or podiatrist, a complete History and Physical must be completed by an MD or DO. prior to leaving the patient unit. OUTPATIENT (including Chemotherapy, Transfusions, etc.) No History and Physical Required CENTER History and Physical Joint Commission H&Ps must be done within 30 days prior to the initial visit H&P Update – Unless moderate sedation or anesthesia is used to perform the treatment, an upate is not required for subsequent visits for the same wound if a progress note with a description of the wound is documented for each visit. Dictated or handwritten Physician’s Notes Complaint History of Present Illness Relevant Past, Social, and Family Histories Review of Systems Relevant Physical Examination of all pertinent systems (minimum mandatory requirement of heart and lung exam) Diagnosis/Impression Treatment Plan and documentation of discussion of reasons for any limited treatment plan and patient and/or family informed of the plan MD, DO, oral surgeon, dentist, or podiatrist PA NP PA, NP, Midwife and Medical Students For PA, NP, Midwife and Medical Students, H&Ps must be at the time of entry by the supervising provider. For Scribes, H&Ps must be authenticated at the time of by the supervising provider and
prior to leaving the patient unit. EMERGENCY DEPARTMENT PATIENTS Emergency Department Report Joint Commission Medicare Conditions of Participation Completed upon discharge from the ED Dictated or handwritten Emergency Department Report – dictated ED Physician Record – handwritten Complaint History of Present Illness Relevant Past, Social, and Family Histories Review of Relevant Systems Physical Exam of the systems pertinent to the chief complaint to include vital signs Diagnosis Treatment Plan and documentation of discussion of reasons for any limited treatment plan and patient and/or family informed of the plan Documentation of what is to be done as an inpatient that cannot be done as an outpatient, how outpatient therapy failed, and reasons why problems were not resolved during previous or recent admissions for the same diagnosis MD/DO PA NP Midwife PA, NP, Midwife and Medical Students Scribe** For PA, NP, Midwife and Medical Students, H&Ps must be at the time of entry by the supervising provider. For Scribes, H&Ps must be authenticated at the time of entry by the supervising provider and prior to leaving the patient unit. HOSPICE PATIENTS History and Physical History and Physical from the acute inpatient stay will be copied to the Hospice record. See Inpatient on page ix. OB PATIENTS History and Physical Joint Commission Medicare Conditions of Participation Within 24 hours of admission Prior to performing a cesarean section H&P Update: An update must be completed, by a member of the medical staff, immediately prior to a procedure requiring anesthesia indicating that the H&P was reviewed, the patient examined, and “no change” has occurred since H&P completion OR document any changes in patient condition prior to procedure requiring anesthesia. Dictated or handwritten OB H&P Physician Progress Notes Dictated Prenatal Record must be on the inpatient record Chief Complaint History of Present Illness Relevant Past, Social, and Family Histories Review of Relevant systems Physical Exam of all pertinent systems (minimum mandatory requirement of heart and lung exam) to include vital signs, and labor progress Admitting/Provisional Diagnosis or Impression Treatment Plan and documentation of discussion of reasons for limited treatment plan and patient and/or family informed of the plan MD, DO Midwife Resident PA, NP, Midwife and Medical Students Scribe** Supervising physician must co-sign all H&Ps performed and documented by a resident. For PA, NP, Midwife and Medical Students, H&Ps must be at the time of entry by the supervising provider.
For Scribes, H&Ps must be authenticated at the time of entry by the supervising provider and prior to leaving the patient unit. NORMAL NEWBORNS (level 3 newborns use Inpatient grid) History and Physical Commission Medicare Conditions of Participation Within 24 hours of admission to performance of a surgical or invasive procedure Handwritten Newborn Physical Examination Record Birth weight, head circumference, chest circumference, length Physical Exam and description of abnormal findings Impression Attending MD, DO PA NP PA, NP, Midwife and Medical Students Scribe** For PA, NP, Midwife and Medical Students, H&Ps must be at the time of entry by the supervising provider. For Scribes, H&Ps must be authenticated by the supervising provider prior to leaving the patient area and prior to leaving the patient unit. *Amended 10/23/11 Approved by BoT 01/23/12 *Amended 04/24/12 Approved by BoT 05/29/12 *Amended 04/23/13 Approved by BoT 05/28/13 *Amended 10/22/13 Approved by BoT 10/28/13 *Amended 04/22/14 Approved by BoT 04/28/14 *Amended 01/11/17 Approved by BoT 01/30/17