History and Physical - Authentication Timeframe

Does a history and physical (H & P) entered into the medical record need to be signed (authenticated) by the author prior to surgery or a procedure requiring anesthesia services, or if completed greater than 24 hours prior to admission/registration, before an update to the H & P can be completed ?

Any examples are for illustrative purposes only.

There are no specific Joint Commission standards that require an H & P to be authenticated prior to surgery, a procedure requiring anesthesia services, or prior to an update being completed.
The standards do require a written policy regarding timely entry of information into a medical record that does not exceed 30 days. A signature is considered an entry.  
State, federal or other regulatory requirements may be more prescriptive when authenticating documents, such as an H & P, in advance of a procedure.
When developing policy, organizations are advised to involve their legal and regulatory leadership to be compliant with these requirements. 
When state or federal law is silent, hospital policy and medical staff rules/regulations should define such requirements.

 
Last updated on May 19, 2020
Manual: Critical Access Hospital
Chapter: Provision of Care Treatment and Services PC

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