What are the requirements for completing a medical history and physical examination?

Any examples are for illustrative purposes only.

Content of history and physical
The organization has the flexibility of determining the content required of the medical history and physical examination to be completed based on the setting(s), service(s) and population(s) served. The organization is required to have a practitioner qualified by the scope of the practitioner's license participate in developing the data to be collected for the physical health screening process to determine a need for a medical history and physical examination (CTS.02.01.05). There are identified requirements in the standards manual for specific service(s), setting(s) and population(s) served. Population groups that have specific medical history and physical requirements and/or assessment are identified in the respective standards. These include:

• CTS.02.02.01 for organizations certified as Behavioral Health Homes
• CTS.02.02.07 and CTS.02.02.09 for Opioid Treatment Programs
• CTS.02.03.03 for Children and Youth
• CTS.02.03.05 for Individuals with Intellectual/Development Disabilities 
• CTS.02.03.09 and CTS.02.03.11 for Eating Disorders Treatment; and
• CTS.02.03.07 and CTS.02.03.13 for Addictions Treatment.

A history and physical examination is to be performed by a physician or a Licensed Practitioner (LP). However, this responsibility can be delegated to any qualified individual consistent with law and regulation and organization's policy. Before allowing the delegation of responsibilities the organization must determine - and be able to demonstrate - whether state law and regulation and professional practice acts allows such delegation and under what circumstances. The definition of LP can be found in the glossary of the Accreditation Manual.

If state law and regulation and professional practice acts allows delegation of a history and physical examination then, the organization must have a process to ensure:

• Only authorized staff conduct history and physicals. 
• Only authorized staff perform the components of a history and physical examination that have been delegated by a Physician or LP.
• The medical history and physical examination is performed under the supervision of, or through appropriate delegation by, a specific qualified physician who countersigns in accordance with law, regulation and organizational policy, and retains accountability for the patient's medical history and physical examination.

Note: Above guidelines are also applicable to medical students. 

Time frame for completion
The organization has the flexibility of determining the time frame for completing the medical history and physical examination (H & P) based on the setting(s), service(s) and population(s) served. 

H & P must be signed and completed within the time frame specified by the needs of the individual served, organization policy, and law and regulation (RC.01.01.01 EP 7 and RC.01.02.01 EP 3). 

For Non-Medical Psychiatric Evaluation or Comprehensive Assessment, the organization defines the time frame for completion based on their setting, services and population served and state law and regulation as required by CTS.02.01.03 EP 2. 

There are identified requirements in the standards manual for specific service(s), setting(s) and population(s) served. Setting(s) and Service(s) that have specific time frames for completing H & P requirements are identified in the respective standards. These include:

• CTS.02.01.07 EP 1. for In-Patient Crisis Stabilization Unit/Acute 24-hour settings that require H and P within 24 hours of admission
• CTS.02.01.07 EP 3. for Opioid Treatment Programs that require H and P within 14 days of admission
• CTS.02.01.06 EP 3. for Residential Treatment Facilities that require H &P within 30 days of admission, and
• CTS.02.01.05 for Out-Patient/non-24-hour settings that require completion of a physical health screening to identify a need for H & P and if the time frame from the last physical examination exceeds 1 year to complete one internally or provide a referral