Guidlines for Hosptial Policy Essay

1442 Words Nov 29th, 2014 6 Pages
Rasmussen Medical Center
Policy: Health Record Documentation Requirements
Approval Date: xx/xx/xxxx
Policy Group: Medical Staff Bylaws

All medical staff and health care providers shall:
History & Physical
1. A complete history and physical examination shall, in all cases be done no more than 7 days before or 24 hours after the admission of a patient. Physical examinations may be used from the previous hospitalization if the examination was within 30 days. A physical examination may be accepted from a physician’s office if the examination was within 30 days and meets the standards as defined by hospital policy and procedure. If the patient was transferred from another
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Ambulatory Surgeries iii. C-section deliveries/tubal ligations iv. Endoscopies
v. Cardioversions
e. The prenatal record may be substituted for a history and physical but an interval admission note must be documented that includes pertinent additions to the history and subsequent changes in the physical findings. In the event a prenatal record is not present, a complete history and physical must be provided.
f. Histories and Physicals completed by a physician assistant or nurse practitioner will be counter-authenticated by their supervising physician.
i. Responsibility for History & Physical – The attending medical staff member is responsible for the History & Physical, unless it was already performed by the admitting medical staff member. History & Physical’s performed prior to admission by a practitioner not on the medical staff are acceptable provided that they are updated timely by the attending physician. Dentists and podiatrists are responsible for the part of their patients' History & Physical that relates to dentistry or podiatry, in addition to the medical history & physical
g. Guidelines for H&P
i. Medical history ii. Chief complaint iii. History of the current illness, including, when appropriate, assessment of emotional, behavioral and social status iv. Relevant past medical, family and/or social history appropriate to the patient's age.
v. Review of body systems. vi. A list of current medications and

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