History and Physical - Update Requirements

When is an update to a history and physical required?

When a history and physical (H & P) is completed within 30 days PRIOR TO inpatient admission or registration of the patient, an update is required within 24 hours AFTER the patient physically arrives for admission/registration but prior to surgery or a procedure requiring anesthesia services.  For example, if an H & P was completed in a physician’s office at 3:00 pm today for a procedure to be performed at 9:00 am tomorrow, an update would be required AFTER the patient arrives for the procedure tomorrow morning but prior to the 9:00 am procedure time. The 24 hour time frame starts when the patient physically presents for admission/registration.  NOTE: The term 'registration' generally applies to patients scheduled for same day or outpatient procedures. Any H & P completed greater than 30 days prior to inpatient admission or registration cannot be updated and a new H & P must be completed.

Accreditation requirements that apply to H & Ps and updates include:
  • Medical Staff (MS):       MS.01.01.01 EP 16
  • Medical Staff (MS):       MS. 03.01.01 EP 6, 7, 10, 11
  • Provision of Care (PC): PC.01.02.03 EP  4
  • Record of Care (RC):    RC.01.03.01 EP  4
  • Record of Care (RC):    RC.02.01.03 EP  3

Last updated on April 17, 2020
Manual: Hospital and Hospital Clinics
Chapter: Provision of Care Treatment and Services PC

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