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History and Physical--Non-Credentialed Practitioners

Can the organization utilize a history and physical that has been performed by someone who is not privileged by the organization?

Any examples are for illustrative purposes only.

The organization can have a requirement, such as in the medical staff rules, regulations or bylaws, that would permit the use of a history and physical examination performed by any practitioner permitted by state law. In this situation a practitioner who is privileged by the organization, permitted by state law,  organization policy and familiar with the organization's requirements for the history and physical must do the following:
review the history and physical examination document
determine if the information is compliant with the organization's history and physical policy/bylaws/rules and regulations
obtain missing information through further assessment and update information and findings as necessary, which may include, but are not limited to:
  • inclusion of absent or incomplete required information,
  • a description of the patient's condition and course of care since the history and physical examination was performed, and 
  • a signature and date on any document with updated or revised information as an attestation that it is current.
Last updated on June 29, 2020
Manual: Ambulatory
Chapter: Provision of Care Treatment and Services PC

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