Q: Should the H&P whether dictated or written be on the record within 24 hours of admission or before surgery?
A: There is no requirement that the H&P be dictated. A handwritten H&P that includes all required elements would be acceptable.
With regard to whether a dictated history and physical examination that has not yet been transcribed meets the intent, the answer is NO except in emergencies (see below). The intent of standards PC.13.20 and PC.13.30 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. A dictated history and physical examination available by phone or electronically does not meet this requirement until an individual transcribes the dictated H&P by listening to it over the phone and the physician who dictated it agrees that it has been transcribed accurately and placed on the record.
The dictated H&P is authenticated as specified by the hospital policy or medical staff bylaws or as required by state or federal law and regulation.
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.