Health Information Technologies and Processes

H&P Requirements

  • 1.  H&P Requirements

    Posted 10-18-2019 08:35
    Good Morning everyone,

    I work for an out patient surgery center in Indiana. Recently, there has been a lot of focus on making sure there is documentation within the H&P stating that the surgeon examined heart and lung. The last time the board of health was here they really focused on this. We also just had a medical records audit and she was looking pretty close for this as well.

    I have researched and I'm not finding any guideline stating that this is mandatory. I'd like to see in black and white what is required for an H&P. My director and manager have also researched and we are all coming up with nothing.

    FYI, anesthesia does chart a pretty extensive exam including heart and lung.

    Thank you in advance.

    Dulcey Speck, RHIT
    Electronic Document Management Technician

  • 2.  RE: H&P Requirements

    Posted 10-21-2019 11:54

    Hi all,


    I'm interested on this as well.  Thanks. 


    Leah R Beck, RHIA

    Assistant Director

    Health Information Management




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  • 3.  RE: H&P Requirements

    Posted 10-22-2019 08:01
    Google "CMS IOM".  (IOM-Internet only manuals).  CMS has a library of regulations based on the entity available for access and review.
    Manual 100-07 - State Operations Manual includes an Appendices Table of Contents.  Appendix Letter "L" links you to the Ambulatory
    Surgery Centers.  (You can also google "State Operations Manual Appendix L"; however, I wanted to provide you the full listing of CMS resources).   Take some time to look through this resource.

    This is one of several resources published by CMS to provide guidance for facilities who receive reimbursement from Medicare/Medicaid.
    Section 416.47  of the Ambulatory Surgery Centers Manual addresses medical records.  It also refers you to other state operations manuals for further information.

    The pre-op assessment of the heart and lungs by the surgeon prior to the start of surgery is a requirement in hospitals as well.  Both CMS and Joint Commission consider this a standard of care ensuring the safety of the patient.

    Mary Meysenburg, MPA, RHIA, CCS


  • 4.  RE: H&P Requirements

    Posted 10-21-2019 13:17



    The medical staff bylaws or policy and procedures must specify the mandatory components to be included in the H&P. For outpatient procedures, it is permissible to have a focused rather than a complete H&P. The bylaws or policy should specify the required components of this format as well. CMS does give some guidelines as well. Hope this helps.