As a result of a recent Joint Commission survey of the ambulatory surgery center, the following reminders are important for all areas.
1) H&P Updates - Patient history and physicals are updated prior to procedures and surgeries. Documentation of this update needs to include indication that the patient was examined and previous information reviewed to determine that no change has occurred. For example, "Exam done - no changes since last H&P." Any information regarding the update should not be documented on the form prior to examining the patient. Forms pre-printed with an update statement are not acceptable and any stamps utilized to standardize documentation of an examination should be placed on the history and physical only after the update examination has been completed. Hospital staff may not pre-stamp forms prior to the update examination occurring."
2) Various H&P forms and formats are being seen from physician offices. Use of alternate forms can contribute to not having the all correct/complete components present. The Standardized History and Physical /Consult Form (#5800709) should be utilized for all inpatient history and physicals/consults. The Outpatient History and Physical Assessment Form (#5220066) may be used for outpatient procedures only. For procedures other than cardiac surgery, these forms should be used in conjunction with the "Pre-Operative Cardiac Risk Assessment Form (#5440066) as needed.
Thank you for your attention to these documentation issues.