Standards FAQ Details | Joint Commission

We published an updated version of our Privacy & Cookies Statement on May 18, 2018. Please take the time to read the updated Privacy & Cookies Statement. This site uses cookies and other tracking technologies to assist with navigation, providing feedback, analyzing your use of our products and services, assisting with our promotional and marketing efforts, and provide content from third parties. Cookies Statement 

Follow us on Twitter Friend us on Facebook Vimeo linkedIn Share with your Friends Print this Page
Friday 9:53 CST, May 25, 2018

Standards FAQ Details


Provision of Care, Treatment, and Services (PC) (Critical Access Hospitals / Critical Access Hospitals)

History and Physical - Update Requirements When Procedures are Performed During Inpatient Stay
Modify | March 31, 2017
What are the requirements for updating a history and physical when surgery or a procedure requiring anesthesia services is performed at a later point during an admission?

If the history and physical (H & P) is completed as required (see PC.01.02.03 EP 4), then a surgical procedure or other procedure requiring anesthesia services is to be completed at a later point during the admission, an update to the H & P is not required as the daily progress notes serve as the updates. The medical staff is responsible for determining who is responsible for entering daily progress notes as well as the required contents of such notes.

To summarize, a properly executed history and physical is valid for the entire length of stay.  Any changes to the patient’s condition would be documented in the daily progress notes.  A new H & P or update to the H & P is not required when the patient remains continuously hospitalized. If the patient has been discharged, then readmitted, there must be a valid history and physical (no greater than 30 days) and updated within 24 hours after re-admission/registration but prior to a surgical procedure or other procedure requiring anesthesia.

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


Was this response helpful?

Comments (Optional - For internal use only)
Thank you for your feedback!