Medical Staff (MS) (Hospital and Hospital Clinics / Hospitals)
History and Physical - Outpatient Procedures
Publish | January 01, 0001
Do patients receiving non-inpatient services such as outpatient surgery, therapy services, laboratory and x-ray service require a history and physical?
In the hospital manual, MS.03.01.01 states "the organized medical staff defines the scope of the medical history and physical examination when required for non-inpatient services". The intent is that the medical staff could define only certain circumstances, such as certain type of outpatient surgeries or procedures such as angiograms, that might require a history and physical.
The medical staff can also define the scope of the assessment. For example, the pertinent relevant history for outpatient surgery for a detached retina might be defined to include only, the history of the trauma or activity that resulted in the detachment, the patient's history of cardiac and respiratory history and current medications to determine appropriate choice of anesthesia, and an assessment of the current condition of the retina and the patient's current vital signs. The pertinent, relevant history for an angiogram might be defined to include a history of cardiovascular problems including chest pain or tightness, medication history, and appropriate lab work. However, any procedure that involves anesthesia or surgery services requires an history and physical to be completed and on the medical record.
Was this response helpful?
Thank you for your feedback!