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.
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.