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Creating specialty-specific H&Ps

HIM Connection, June 2, 2009

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Q: Has anyone developed specialty-specific history and physical (H&P) forms, such as an H&P for an orthopedic admission, an H&P for a medical admission, or an H&P for general surgery? We use the same H&P for all admissions and day surgery visits; however, our surgeons have challenged these forms on the basis that there are many items that are irrelevant to surgery admissions. For example, they want to limit the physical exam to a general exam (i.e., heart, lungs, and chest). They do not want to examine the abdomen, back, head, ears, eyes, nose, throat, or any other areas that might be more relevant to a general admission.

A: There is no regulation that requires specialty-specific H&Ps. Medical staff members should identify—at a minimum—what the H&P should include. For example, our policy states that at a minimum, the H&P for both inpatient and outpatient visits must include:

• A history related to the admission/surgery
• Examination of the heart, lungs, and mental status
• A specific examination related to the condition for which the patient is being treated

It also includes a plan for anesthesia, when appropriate, and a plan of care.

Editor’s note: Jean S. Clark, RHIA, CSHA, service line director for health information management services at Roper Saint Francis Healthcare in Charleston, SC, answered this question.

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