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History and Physical - Dictated not Transcribed

Does a dictated history and physical examination that has not yet been transcribed and attached to the medical record, meet the intent of the standards?

Any examples are for illustrative purposes only.

The answer is NO except in emergencies*. The intent of the ambulatory standards related to Operative or Other High-Risk Procedures and/or the Administration of Moderate, Deep Sedation or Anesthesia is, the organization performs and documents a history and physical examination (see PC.03.01.03 ). The organization must complete this within 30 days before the procedure.  

The mere existence of a dictated history and physical, not transcribed and entered in the patient's medical record, is not in compliance with the intent of the standard. The history and physical is essential information needed to further assess and manage the patient. 

* 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.
Last updated on August 24, 2021
Manual: Ambulatory
Chapter: Provision of Care Treatment and Services PC

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