Health Information Management

Q&A: H&P for patients undergoing moderate or deep sedation?

HIM-HIPAA Insider, September 21, 2010

Want to receive articles like this one in your inbox? Subscribe to HIM-HIPAA Insider!

Q: Is a history and physical (H&P) exam necessary for patients undergoing moderate or deep sedation?

A: The relevant Conditions of Participation regarding medical records include the following:
 
§482.24(2)i.(A) – A medical history and physical examination must be completed and documented no more than 30 days before or 24 hours after admission or registration, but prior to surgery or a procedure requiring anesthesia services. The medical history and physical examination must be placed in the patient’s medical record 24 hours after admission or registration, but prior to surgery or a procedure requiring anesthesia services. (A-0458)
 
(B) – The medical record must include an updated examination of the patient, including any changes in the patient’s condition, when the medical history and physical examination are completed within 30 days before admission or registration. The updated examination must be documented in the patient’s medical record within 24 hours after admission or registration, but prior to surgery or a procedure requiring anesthesia services. (A-0461)
 
 These requirements are also referenced under Surgical Services §482.51(b)(1)i & ii.
 
These requirements would lead you to believe that you only need an H&P and update for patients undergoing anesthesia, not for those undergoing moderate or deep sedation.
 
However, I contacted The Joint Commission’s (formerly JCAHO) Standards Interpretation Group and was told that yes, an H&P would be required for patients receiving moderate or deep sedation in both inpatient and outpatient settings. The update would be required as needed.
 
To comply with these standards, you need a policy approved by the medical staff that defines the instances in which an H&P is required for moderate or deep sedation, such as for endoscopies, cardiac catheterizations, interventional radiology as defined by the radiologists, or procedures performed in the ambulatory surgery suite.
 
This policy can be included in the medical staff rules and regulations or in a separate policy. Your physicians could use a shorter H&P as long as it meets the minimum requirements as defined by the medical staff for content of any H&P.
 
Editor’s note: This Q&A, answered by Jean S. Clark, RHIA, CSHA, service line director for HIM at Roper Saint Francis Hospital in Charleston, SC, was adapted from an article in the September issue of Medical Records Briefing.



Want to receive articles like this one in your inbox? Subscribe to HIM-HIPAA Insider!

Most Popular