Provision of Care, Treatment, and Services (PC) (Nursing Care Center / Nursing Care Center)
History and Physical - Authentication Time Frame
Modify | April 11, 2016
Does a dictated and transcribed history and physical need to be authenticated within 72 hours (48 hours for subacute) in order to be considered complete?
No. Each patient must have a history and physical performed and documented within 72 hours of admission as an inpatient. This includes weekend and holidays. History and physicals are dictated, transcribed, authenticated and placed in the medical/clinical record, based on organizational policy. When there is a transcription delay, a handwritten note signed by the licensed independent practitioner and placed in the record containing pertinent findings, (i.e., enough information record within 72 hours of admission for clinicians to manage the patient and guide the plan of) care would be acceptable.
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