Provision of Care, Treatment, and Services (PC) (Hospital and Hospital Clinics / Hospitals)
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?
History and Physical - Update Requirements When Procedures are Performed During Inpatient Stay
Modify | March 31, 2017
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 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