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History and Physicals - Understanding the Requirements

What are the key elements organizations need to understand regarding History and Physical Requirements ?

Any examples are for illustrative purposes only.

It is the responsibility of the organized medical staff to determine the minimum required content of medical history and physical (H & P) examinations (see MS.03.01.01 EP 6).  The required content is relevant and includes sufficient information necessary to provide the care, treatment and services required addressing the patient's condition, planned care and assessed needs. 
The specific content may vary based on services provided and patient population served by the care setting. An H & P must be completed and entered into the medical record for any high-risk procedure, surgical procedure and any procedure that involves anesthesia services.

Qualified Practitioners:
The H & P must be completed and documented by a qualified and privileged physician or other qualified licensed practitioner privileged to do so in accordance with state law and organizational policy. 

Other qualified licensed practitioners could include nurse practitioners and physician assistants.  More than one qualified practitioner can participate in performing, documenting, and authenticating an H&P for a single patient. When more than one practitioner participates in completing the H & P, each entry must be signed, dated and timed by the author of that entry. 

Podiatrists and Dentists
The medical staff must determine, based on state-specific law and regulation (Scope of Practice), the extent to which a Dentist or Podiatrist may complete a history and physical. Typically, the Dentist or Podiatrist is only authorized to perform aspects of the History and Physical that are applicable to either Dentistry or Podiatry.

Practitioners Without Privileges  
The organization can have a policy 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 (see MS.03.01.01 EP 8), as permitted by state law and organization policy and familiar with the organization's policy for the defined minimal content of the history (see MS.03.01.01 EP 6) and physical must:
• review the history and physical examination document;
• determine if the information is compliant with the organization's defined minimal content;
• obtain missing information through further assessment 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.

Medical Students
A medical student has no legal status as a provider of health care services, therefore, a medical History and Physical (H&P) conducted by a medical student would not fulfill the requirements. 

Non-inpatient Services (e.g. Outpatient surgery, interventional and diagnostic procedures, therapy services, infusion centers, wound care centers, laboratory, etc).
MS.03.01.01 EP 11 (HAP only) requires that "the organized medical staff defines the scope of the medical history and physical examination when required for non-inpatient services". The intent is that the medical staff defines only certain circumstances, such as certain type of outpatient surgeries or procedures such as angiograms, that require a history and physical.

For hospitals that use Joint Commission accreditation for deemed status purposes, the medical staff may choose to develop and maintain a policy for the identification of specific patients to whom the assessment requirements would apply, in lieu of a comprehensive medical history and physical examination (see MS.03.01.01 EP 19).  The policy must be based on the following:
• Patient age
• diagnoses, the type and number of surgeries and procedures scheduled to be performed, 
• comorbidities, and the level of anesthesia required for the surgery or procedure
• Nationally recognized guidelines and standards of practice for assessment of particular types of patients prior to specific outpatient surgeries and procedures
• Applicable state and local health and safety laws

Authentication Timeframe:
There are no specific Joint Commission standards that require a dictated/transcribed H & P to be authenticated prior to surgery, a procedure requiring anesthesia services or prior to an update being completed. However, organizations are expected to have a written policy (see RC.01.03.01) requiring timely entry of information into a medical record that does not exceed 30 days. A signature (authentication) is considered an ‘entry’.

When developing such a policy, organizations should involve their legal and regulatory leadership to determine any state, federal or other regulatory requirements that may be more prescriptive when authenticating documents, such as an H & P, in advance of a procedure. Where state or federal law is silent, hospital policy and medical staff rules/regulations should define such requirements.

Dictated but not transcribed: 
The mere existence of a dictated history and physical that has not been transcribed and entered in the patient's medical record is not in compliance with the intent of the requirements as essential information needed to further assess and manage the patient would not be available to the patient care team. 

Last updated on March 19, 2021
Manual: Critical Access Hospital
Chapter: Provision of Care Treatment and Services PC

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