Health Information Technologies and Processes

H&P's over 30 days (mostly for outpatient procedures)

  • 1.  H&P's over 30 days (mostly for outpatient procedures)

    Posted 16 days ago
    We are having an issue with receiving H&P's from physician offices that are over 30 days from the date of surgery. We do not accept H&P's older than 30 days. The physicians are complaining because they said sometimes they cannot schedule a patient for surgery within 30 days of their office visit and they do not feel like they should have to do an entirely new H&P when the one done in the office has the necessary requirements. Do you all have any issues with this? How do you handle?

    This is a bigger issue for us since our surgery dept. does not stop the procedure from being scheduled or happening as long as there is an H&P (even if it's older than 30 days). So basically we don't realize it until the chart gets to HIM after the procedure has already been done. At that point it seems pointless for a physician to go back and do an H&P after the fact. Thoughts??

    ------------------------------
    Mikki Medine
    Him Director
    Thibodaux Regional Medical Center
    ------------------------------


  • 2.  RE: H&P's over 30 days (mostly for outpatient procedures)

    Posted 15 days ago

    Can the physician not just document he/she reviewed the H&P and there were no changes or note any changes? 

     

    Brenda Huntsinger,

    RHIT, LNHA

    Instructor

    bhuntsinger@atu.edu

    ATU-Ozark Campus

    Health Information Technology

    Health Sciences and Wellness

    Room 225

    1700 Helberg Lane

    Ozark AR 72949

    479 508 8500

     






  • 3.  RE: H&P's over 30 days (mostly for outpatient procedures)

    Posted 15 days ago
    Hello,

    CMS updated new requirements relating to ASC H&P requirements effective 2019:


    Number 2, C:

    "ASC REQUIREMENTS FOR COMPREHENSIVE MEDICAL HISTORY AND PHYSICAL ASSESSMENT

    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.







  • 4.  RE: H&P's over 30 days (mostly for outpatient procedures)

    Posted 15 days ago

    Thank you Rachael!

     

    Brenda Huntsinger,

    RHIT, LNHA

    Instructor

    bhuntsinger@atu.edu

    ATU-Ozark Campus

    Health Information Technology

    Health Sciences and Wellness

    Room 225

    1700 Helberg Lane

    Ozark AR 72949

    479 508 8500

     






  • 5.  RE: H&P's over 30 days (mostly for outpatient procedures)

    Posted 15 days ago
    wow was not aware of this change!! What about joint commission? have they jumped on board with this?

    ------------------------------
    Mikki Medine
    Him Director
    Thibodaux Regional Medical Center
    ------------------------------



  • 6.  RE: H&P's over 30 days (mostly for outpatient procedures)

    Posted 15 days ago

    Not that I am aware of.

     






  • 7.  RE: H&P's over 30 days (mostly for outpatient procedures)

    Posted 15 days ago
    I am not sure, but this is the link  to the joint commission 2020 update for the ASC manual. I'm sure the answer will be in there. I tried to find a free accurate online answer for you, but the closest answer I can get is that joint commission leaves up to the hospital to determine contents of H& P and must conform to state guidelines. 



    The last updated FAQ regarding timeframe and H&P is 2017:



    When is an update to a history and physical required?
    When a history and physical (H & P) is completed within 30 days PRIOR TO inpatient admission or registration of the patient, an update is required within 24 hours AFTER the patient physically arrives for admission/registration but prior to surgery or a procedure requiring anesthesia services.  For example, if an H & P was completed in a physician's office at 3:00 pm today for a procedure to be performed at 9:00 am tomorrow, an update would be required AFTER the patient arrives for the procedure tomorrow morning but prior to the 9:00 am procedure time. The 24 hour time frame starts when the patient physically presents for admission/registration.  NOTE: The term 'registration' generally applies to patients scheduled for same day or outpatient procedures. Any H & P completed greater than 30 days prior to inpatient admission or registration cannot be updated and a new H & P must be completed.

    Accreditation requirements that apply to H & Ps and updates include:
    • Medical Staff (MS):       MS.01.01.01 EP 16
    • Medical Staff (MS):       MS. 03.01.01 EP 6, 7, 10, 11
    • Provision of Care (PC): PC.01.02.03 EP  4
    • Record of Care (RC):    RC.01.03.01 EP  4
    • Record of Care (RC):    RC.02.01.03 EP  3

     
    Last updated on April 24, 2017



    Below is the link to the 2020 joint commission  update for ASC: 



    Hope this information helps. 

    Sincerely,
    Rachel Roblez, RN, BSN, CNOR, & CTR hopeful.
    raychellegrayce@hotmail.com





  • 8.  RE: H&P's over 30 days (mostly for outpatient procedures)

    Posted 15 days ago
    Hello,

    When in doubt, you can also consult directly with Joint Commission and decide whether your current practice conforms with accreditation requirements or if your policy & procedures need to change.

    Here is the link of thier contact list.

    Additionally,
    I suggest some kind of meeting comprising of hospital  policy/procedures committee,  cheif of surgery, OR director, OR manager & OR nurse educator, HIM director to get together to discuss department needs in relation to CMS & Joint Commission accreditation requirements. Frustration happens when knowledge deficit exist- everyone needs to agree to existing policy or change in policy. Education is critical to desiminate the same information across all the departments. Surgeons practice at multiple facilities with multiple documentation requirements. Physician offices need a way to recive hospital policy updates in a timely fashion.  Enforcement is also key in keeping the organization strong. As a last stop/gatekeeper, the circulator nurse runs into this H&P issue on a daily basis. Enforcement has commonly been the revocation of physician priviledges until documentation is completed to standard. Should there ever be a question, The RN circulator should have access to this list of priviledges before surgery can commence. This has been my experience as an operating room nurse and so I'm only speaking from personal experience of what I've come to find has been the most effective way of implementing change. 

    Hope this information is helpful for you.






  • 9.  RE: H&P's over 30 days (mostly for outpatient procedures)

    Posted 14 days ago
    Noticed that the original question came from a Med Center, not specifically an ASC. Would point out that this same CMS document also includes guidance for Hospitals. Interestingly institutions are being afforded the opportunity (not requirement) to customize their pre-op H&P content, timing, etc. based on procedure, etc. So hospitals continuing to require H&P w/in 30 days are in compliance but Hospitals have the option to modify rules/regs and P&P.  Compliance will be determined based on alignment between practice and policy of the Hospital. (ASC is in Section 2...continue to Section 4 for Hospitals).
    Currently there is no change in JC's  max 30-day pre-op H&P in the Hospital standards.
    - Kay Folck, MHA, RHIA
    HIM Educator

    ------------------------------
    Kealia Folck
    ------------------------------



  • 10.  RE: H&P's over 30 days (mostly for outpatient procedures)

    Posted 15 days ago

    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.


    Thanks,

    Karla