Accreditation

Q&A: Clarifying PC.01.02.01 EP23 (Incomplete preprocedure H&P)

Accreditation Insider, July 10, 2012

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Q: During our recent survey, the surveyor cited three instances where the preprocedure H&P was missing elements based on the medical staff rule requirements. How can I clarify this?

A: Consider the following in this case for a clarification:

  • What do the bylaws state regarding the minimum components of H&Ps for outpatients?
  • Are exceptions noted in the number of criteria needed for specific procedures?

Based on the number of procedures requiring an H&P, these three citations should fall as a minority in the total numerator and denominator to demonstrate 90% compliance and can be cleared by performing the audit.

Editor’s Note: Do you have a question about clarifying RFIs, policy management, or survey-prep for our experts? E-mail your queries to Jaclyn Beck at jbeck@hcpro.com and receive one-on-one advice from our experienced advisory board. Submit a question and our credible sources will provide you with a timely answer.



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