Medical Staff (MS) (Hospital and Hospital Clinics / Hospitals)
History and Physical - Non-Credentialed Practitioners
Modify | April 11, 2016
Can the organization utilize a history and physical that has been performed by someone who is not privileged by the organization?
The organization can have a policy that would permit the use of a history and physical examination performed by any practitioner permitted by state law. In this situation a practitioner who is privileged by the organization (see MS.03.01.01 EP 8), as permitted by state law and organization policy and familiar with the organization's policy for the defined minimal content of the history (see MS.03.01.01 EP 6) and physical must:
- review the history and physical examination document;
- determine if the information is compliant with the organization's defined minimal content;
- obtain missing information through further assessment update information and findings as necessary, which may include, but are not limited to:
- inclusion of absent or incomplete required information,
- a description of the patient's condition and course of care since the history and physical examination was performed, and
- a signature and date on any document with updated or revised information as an attestation that it is current.
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