History and Physical - Dictated not Transcribed
Does a dictated history and physical examination that has not yet been transcribed and attached to the medical record, meet the intent of the standards?
Any examples are for illustrative purposes only.
No, an H & P that has only been dictated and not placed in the medical record would not be compliant, except in emergencies^. 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 standards as essential information needed to further assess and manage the patient is absent.
Standard RC.02.01.03 is specific in the requirement that the patient's medical history and physical examination are recorded in the medical record before an operative or other high-risk procedure is performed.
^In an emergency, when there is no time to record the complete history and physical examination, a progress or admission note describing a brief history and appropriate physical findings and the preoperative diagnosis is recorded in the medical record before surgery.
No, an H & P that has only been dictated and not placed in the medical record would not be compliant, except in emergencies^. 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 standards as essential information needed to further assess and manage the patient is absent.
Standard RC.02.01.03 is specific in the requirement that the patient's medical history and physical examination are recorded in the medical record before an operative or other high-risk procedure is performed.
^In an emergency, when there is no time to record the complete history and physical examination, a progress or admission note describing a brief history and appropriate physical findings and the preoperative diagnosis is recorded in the medical record before surgery.
Manual:
Hospital and Hospital Clinics
Chapter:
Record of Care Treatment and Services RC
Last reviewed by Standards Interpretation: May 02, 2022
Represents the most recent date that the FAQ was reviewed (e.g. annual review).
First published date: April 11, 2016
This Standards FAQ was first published on this date.
This page was last updated on May 02, 2022
with update notes of: Review only, FAQ is current
Types of changes and an explanation of change type:
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Reflects new or updated requirements: Changes represent new or revised requirements.
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