Health Information Management

History and physical reports clarified

HIM Briefings, September 1, 2010

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I have received several questions related to my “Standards of the month” column about history and physical (H&P) reports. 

I thought it would be a good idea to clarify two specific issues these inquiries raised: 1) the requirements for H&P examinations for moderate sedation, and 2) allowing anesthesiologists to complete the update to the H&P report prior to surgery.

This is an excerpt from a member only article. To read the article in its entirety, please login or subscribe to HIM Briefings.

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