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Cohesive History and Physical Requirements

Accreditation Monthly, January 15, 2010

When was the last time you checked your organization's written history and physical (H&P) requirements against the federal rules? CMS' Conditions of Participation state that the requirements for completing and documenting patient histories and physical examinations are contained in the medical staff bylaws (CFR §482.22 [c][5][i-ii]). The Joint Commission also addresses these requirements in the Medical Staff (MS.01.01.01, EP 20, and MS.03.01.01) and Provision of Care (PC.01.02.03, EPs 4 and 5) chapters of the hospital standards. This means that H&P completion requirements must reside in the medical staff bylaws, whereas specific content requirements can be addressed in the hospital's rules and regulations. In other words, your bylaws should indicate the time frame in which the H&P must be completed and who can perform them.

Required time frame
The requirements clearly state that the H&P be completed no more than 30 days before or 24 hours after admission and prior to procedures requiring anesthesia services. For outpatient procedures or same-day admissions when the H&P is completed within 30 days prior to the procedure, an update is required after admission and prior to the procedure.

Who can perform an H&P?
The H&P must be performed by a qualified licensed practitioner in accordance with state law and hospital policy.

What is included in the H&P?
The medical staff bylaws or policy and procedures must specify the mandatory components to be included in the H&P. For outpatient procedures, it is permissible to have a focused rather than a complete H&P. The bylaws or policy should specify the required components of this format as well.

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