Provision of Care: History and Physical

Joint Commission Derby Week 2

 

H & P must be completed & documented within 24 hrs. following admission of the patient, but prior to surgery or a procedure requiring anesthesia services (including moderate sedation).

 

H&P Exams performed within 30 days prior to admission may be used if the following requirements are met:

• Physician writes an update note which is written on or attached to the H&P.
• The words “re‐examined the patient” must be present. Required by CMS.
• The H&P and any updates/assessments must be included in the medical record within 24 hrs. of admission, but prior to surgery or other procedures whichever comes first.

H&P performed more than 30 days prior to admission, outpatient, observation, or outpatient surgery does not comply with timeliness requirements and a new H&P must be performed.

• H&P Required Components: Chief Compliant, Details of Present Illness, Relevant Past, Social and Family History, Physical Examination, Statement on conclusions
• Short Form H&P can be used for a hospital stay not expected to exceed 24 hrs. – At a minimum: Vital signs, mental status, heart, lungs and reason for hospitalization must be included

 

Click the link below to download History and Physical PDF for more info.

History and Physical