Q: Does a dictated history and physical examination that has not yet been transcribed and attached to the medical record, meet the intent of PC.2.120 and IM.6.30?
A: The answer is NO except in emergencies (see below). The intent of standards PC.13.20-PC.13.40 related to Operative or Other High-Risk Procedures and/or the Administration of Moderate or Deep Sedation foresees the continuous evaluation of the patient's status throughout the peri-operative period. For care givers to do this well they need immediate access to sufficient information about the patient, i.e. the H&P findings, laboratory and other data, the pre-anesthesia assessment, and the assessment immediately before starting the operation.
The mere existence of a dictated H&P that has not been transcribed and entered in the patient's medical record is not in compliance with the intent of the standards as essential information needed to further assess and manage the patient is absent.
In an emergency, when there is no time to record the complete history and physical examination, a progress or admission note describing a brief history and appropriate physical findings and the preoperative diagnosis is recorded in the medical record before surgery.