Can the physician not just document he/she reviewed the H&P and there were no changes or note any changes?
Health Information Technology
Health Sciences and Wellness
1700 Helberg Lane
Ozark AR 72949
479 508 8500
We are removing the current requirements at § 416.52(a) for a History and Physical within 30 days of the procedure and replacing them with requirements that defer, to a certain extent, to the ASC policy and operating physician's clinical judgment to ensure that patients receive the appropriate pre-surgical assessments tailored to the patient and the type of surgery being performed. We still require the operating physician to document any pre-existing medical conditions and appropriate test results, in the medical record, before, during and after surgery. Start Printed Page 51734In addition, we have retained the requirement that all pre-surgical assessments include documentation regarding any allergies to drugs and biologicals, and that the medical history and physical examination (H&P), if completed, be placed in the patient's medical record prior to the surgical procedure."
Hope this info helps.
Rachel Roblezr, RN, , BSN, CNOR, and CTR hopeful.
Thank you Rachael!
Not that I am aware of.
Hi, we struggled with this for a long time. What we have reiterated and continued to do so is that this a CMS and TJC requirement. We do not make the rules but we do enforce them. We have made our PSS and surgical areas the gatekeepers on this. If the provided has an H&P over 30 days old, the surgeon has to do a short stay H&P on the day of the surgery. We do not accept or scan in an outdated H&P. The important part of this entire process was getting execute level support, which we do have. We also monitor this in our system based practice dashboard that gets reviewed by our Board of Trustees every month. Hope this helps.