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History and Physical - Authentication Timeframe

Does a history and physical (H & P) that has been dictated and placed into the medical record need to be signed (authenticated) by the author prior to a procedure, 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, that has been dictated and placed into the record, to be authenticated prior to a procedure or prior to updating an H & P that was completed within 30 days prior to admission or registration. 

Organizations are required to have a written policy regarding timely entry of information into a medical record that does not exceed 30 days. A signature is considered an entry.  However, 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 a policy, organizations should work with their regulatory leadership and legal counsel to determine any state-specific requirements that must be considered. When state or federal law is silent, hospital policy and medical staff rules/regulations should define such requirements.
Last updated on September 14, 2020
Manual: Critical Access Hospital
Chapter: Record of Care Treatment and Services RC

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