Q: Can the organization utilize a history and physical which has been performed by someone who is not authorized/privileged by the organization?
A: The standards in all manuals require that the history and physical be performed by someone who has been authorized/privileged by the organization.
The organization could, however, have a policy which would allow the use of such a history and physical examination document provided an LIP or other individual who has been authorized/privileged by the organization:
- review the history and physical examination document
- conduct a second assessment to confirm the information and findings
- update any information and findings as necessary (including a summary of the patient's condition and of course of care during the interim period) and the current physical/psychosocial status; and
- sign and date the information as an attestation to it being current