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 ?

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. However, organizations are expected to have a written policy 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.

Accreditation requirements that apply:
• Record of Care (RC):    RC.01.02.01
• Record of Care (RC):    RC.01.03.01 

The organization's individual responsible for accreditation readiness has a copy of the manual containing the full text of standards referenced in this FAQ as they are not published on our website.
 
Last updated on June 20, 2018
Manual: Critical Access Hospital
Chapter: Record of Care Treatment and Services RC

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