Q: Does a dictated and transcribed history and physical need to be authenticated within 24 hours in order to be considered complete?
A: No. Each patient must have a history and physical performed and documented within 24 hours (72 for LTC and 48 for subacute) of admission as an inpatient. This includes weekend and holidays. History and physicals are dictated, transcribed, authenticated and placed in the medical record, based on organizational policy.
When there is a transcription delay, a handwritten note signed by the licensed independent practitioner and placed in the medical record containing pertinent findings, (i.e., enough information on the patient record within 24 hours (72 for LTC and 48 for subacute) of admission for clinicians to manage the patient and guide the plan of care) would be acceptable.