History and Physical Requirements

The following History and Physical (H&P) requirements were pulled from WellStar Medical Staff’s Medical Record Policy, which was last updated in February 2011. In addition to complying with The Joint Commission and Centers for Medicaid & Medicare Services requirements, this is a patient safety issue. Physicians need to know the risks ahead of time in order to make the next decision regarding a patient’s medical care. Please note that items in bold and underlined represent new wording or additional content.


RESPONSIBILITY
An H&P should always be performed by a physician. The physician may delegate all or part of the physical examination and medical history to other medical staff members privileged to do so or allied health professionals with appropriate clinical functions, but the physician is required to sign, date, time and assume full responsibility for these activities and their timeliness.

TIMELINESS

• Unplanned: Completed within 24 hours of admission and prior to procedure

• Planned: An H&P completed no more than 30 days prior to admission may be used provided it is updated within 24 hours of admission and prior to procedure. The update must document the H&P was reviewed, the patient examined, any changes in condition or condition as unchanged, with date, time and authentication.

FORMAT

• Dictated

• Computer-generated

• Handwritten

ELEMENTS
Medical admission or surgical admission requiring moderate or deep sedation or general anesthesia:

• Reason for admission;

• Current medications;

• Allergies to include food(s) and/or medication(s);

• Details of the present illness;

• Clinically relevant past, social, and family histories (appropriate to the patient’s age);

• Review of systems;

• Psychosocial needs (emotional, behavioral), as appropriate to the Patient’s age;

• Prenatal information recorded in obstetrical records which may be an original or a durable, legible reproduction of the office or clinic prenatal record;

• Clinically relevant physical examination;

• A statement of the conclusions, initial or preoperative diagnosis, or diagnostic impression;

• Plan of treatment (course of action).

Emergency, Life-threatening Situations

• In an emergency, when there is no time to record the complete H&P prior to surgery, a note to that effect is entered in the progress notes. The note includes a brief history, the appropriate physical findings, and the preoperative diagnosis.

The updated Medical Records Policy is available on the Physician Portal or by going to
eSource > Departments > Medical Staff Services > Bylaws and Policies.