Provision of Care, Treatment, and Services (PC) (Hospital and Hospital Clinics / Hospitals)
When is an update to a history and physical required?
History and Physical - Update Requirements
Modify | March 31, 2017
When a history and physical (H & P) is completed within 30 days PRIOR TO inpatient admission or registration of the patient, an update is required within 24 hours AFTER the patient physically arrives for admission/registration but prior to surgery or a procedure requiring anesthesia services. For example, if an H & P was completed in a physician’s office at 3:00 pm today for a procedure to be performed at 9:00 am tomorrow, an update would be required AFTER the patient arrives for the procedure tomorrow morning but prior to the 9:00 am procedure time. The 24 hour time frame starts when the patient physically presents for admission/registration. NOTE: The term 'registration' generally applies to patients scheduled for same day or outpatient procedures. Any H & P completed greater than 30 days prior to inpatient admission or registration cannot be updated and a new H & P must be completed.
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