Q&A: Clarifying PC.01.02.03 EP4 (H&P completed within 30 days/24 hours)

Accreditation Insider, June 12, 2012

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Q: The surveyor found three behavioral health H&Ps not placed in the record within 24 hours of admission. Two H&Ps for patients in the endoscopy center had timed entries of 1:17a.m. and 1:23a.m, making it unlikely that the physician had conducted the H&Ps at those times as there was no other entry in the record to indicate time. How can I clarify this?

A: The first step is to determine why the early morning times were recorded in the system and not available to rule out any technical glitch. If you can demonstrate a technical problem through the review, you can probably demonstrate compliance at 90%. Review what elements are actually required for H&Ps in the outpatient setting based on your bylaws or rules and regulations.

  • Is a shortened form acceptable, and were these elements present somewhere in the record, such as in the progress notes? Should these records have been cited if the policy was followed?
  • Review the referenced medical record files for accuracy according to your bylaws or rules and regulations.

Otherwise perform an audit of H&P presence in the record for the period of 30 days prior to the visit. Another item to consider is if the medical records department has a policy stating what data are reviewed on a regular basis. If it does, by using data from completed record reviews through routine monitoring you may already have the data to show 90% compliance.

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 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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