Manual:
Office Based Surgery
Chapter:
Record of Care Treatment and Services RC
Topic:
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, except in emergencies^, an H & P that has been dictated, but not entered into the medical record would not be compliant. The intent of the ambulatory standards related to Operative or Other High-Risk Procedures and/or the Administration of Moderate, Deep Sedation or Anesthesia is, the organization performs and documents a history and physical examination (see PC.03.01.03 ). The organization must complete this within 30 days before the procedure.
The mere existence of a dictated history and physical, not transcribed and entered in the patient's medical record, is not in compliance with the intent of the standard. The history and physical is essential information needed to further assess and manage the patient.
^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, except in emergencies^, an H & P that has been dictated, but not entered into the medical record would not be compliant. The intent of the ambulatory standards related to Operative or Other High-Risk Procedures and/or the Administration of Moderate, Deep Sedation or Anesthesia is, the organization performs and documents a history and physical examination (see PC.03.01.03 ). The organization must complete this within 30 days before the procedure.
The mere existence of a dictated history and physical, not transcribed and entered in the patient's medical record, is not in compliance with the intent of the standard. The history and physical is essential information needed to further assess and manage the patient.
^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.
Last updated on May 02, 2022
with update notes of: Review only, FAQ is current
First Published Date: December 02, 2016
Last Reviewed Date: May 02, 2022