to main content History and Physical - Authentication Time Frame | Nursing Care Center | Provision of Care Treatment and Services PC | The Joint Commission
History and Physical - Authentication Time Frame

Does a dictated and transcribed history and physical need to be authenticated within 72 hours (48 hours for subacute) in order to be considered complete?

Any examples are for illustrative purposes only.

No. Each patient must have a history and physical performed and documented within 72 hours of admission as an inpatient. This includes weekend and holidays. History and physicals are dictated, transcribed, authenticated and placed in the medical/clinical record, based on organizational policy. When there is a transcription delay, a handwritten note signed by the licensed practitioner and placed in the record containing pertinent findings, (i.e., enough information record within 72 hours of admission for clinicians to manage the patient and guide the plan of) care would be acceptable.
Manual: Nursing Care Center
Chapter: Provision of Care Treatment and Services PC
First published date: April 11, 2016 This Standards FAQ was first published on this date.
This page was last updated on November 23, 2022 with update notes of: Editorial changes only Types of changes and an explanation of change type: Editorial changes only: Format changes only. No changes to content. | Review only, FAQ is current: Periodic review completed, no changes to content. | Reflects new or updated requirements: Changes represent new or revised requirements.
Was this response helpful?

If no, please comment on how we could improve this response.

If you have additional standards-related questions regarding this topic, please use the Standards Online Submission Form

Get Extra Help with Books and E-books

Browse our gallery of books and e-books to find trusted prep and readiness resources, practical checklists and toolkits, and resources on specialized health care topics.

Stay Informed with Online Education

Online education is the most convenient and cost-effective way to educate your staff and minimize expenses without the need to leave your organization.

Reach Your Safety Goals with eProducts

Assessing and sustaining compliance with accreditation standards or CMS CoPs can be a challenge, but it doesn’t have to be. Rely on our proven software solutions developed by our team of industry experts.

Can't Find What You're Looking For?

If you do not find an answer to your question, please contact the Standards Interpretation Group (SIG).

Note: To provide adequate support to those organizations that are either accredited/certified or seeking accreditation/certification, we will only answer those questions submitted by those organizations seeking accreditation/certification or currently accredited/certified by the Joint Commission. The Joint Commission no longer answers questions submitted by students or vendors. Thank you for your understanding.