Medical Staff (MS) (Hospital and Hospital Clinics / Hospitals)
History and Physical - Medical Student
Modify | April 11, 2016
Is it acceptable for a medical student to perform and document a history and physical in the medical record?
A medical student has no legal status as a provider of health care services, therefore, a medical History and Physical (H&P) conducted by a medical student would not fulfill the requirements. A practitioner who has been granted privileges by the hospital to do so is required to perform patient medical history and physical examinations and required updates.
Organizations that use Joint Commission accreditation for deemed status purposes may find it helpful to review the CMS Conditions of Participation that address practitioner responsibilities for completing H & Ps. The organization’s individual responsible for accreditation and regulatory compliance should have access to the CMS State Operations Manual (SOM) that contains this information. It is also available by searching the internet.
Under certain circumstances, and as permitted by state law and policy, the organized medical staff may choose to delegate or allow individuals who are not Licensed Independent Practitioners to perform part or all of a patient’s medical history and physical examination under the supervision of, or through appropriate delegation by, a specific qualified doctor of medicine or osteopathy who is accountable for the patient’s medical history and physical examination. The definition of an LIP can be found in the glossary of the organization's accreditation manual.
The following FAQ provides additional detail and clarification regarding delegation:
History and Physical - Delegation to Non Licensed Independent Practitioners
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