Q. What specific data must be included in the history and physical?
A. The history and physical standards do not specify the specific content of the H & P. The medical staff or medical director, when an organized medical staff is not required and does not exist, defines in policies and procedures the specific data to be included. The data should be pertinent and relevant and should include sufficient information necessary to provide the care and services required to address the patient's conditions and needs and may vary by setting or level of care, treatment, and services. As such, the specific data could be different for populations, or setting of care, treatment or services.