update prior to surgery must prior to leaving be completed by a member of the patient unit. the CVMC Medical Staff H&P Update: An update must be completed, by a member of the medical staff, immediately prior to a procedure requiring anesthesia indicating that the H&P was reviewed, the patient examined, and change” “no has occurred since H&P completion OR document any changes in patient condition prior to procedure requiring anesthesia. If the Observation patient converts to inpatient status and the H&P of record was completed by a dentist or podiatrist, a complete History and Physical must be completed by an MD or DO. OUTPATIENT (including Chemotherapy, Transfusions, etc.) No History and Physical Required CENTER History and Physical H&Ps must be done Dictated or Complaint MD, For PA, NP, Physician’s within 30 days prior to the handwritten History of Present Illness DO, oral Midwife and Notes Joint Commission initial visit Relevant Past, Social, and Family surgeon, Medical H&P Update Unless Histories dentist, or Students, H&Ps – moderate sedation or Review of Systems podiatrist must be anesthesia is used to perform Relevant Physical Examination of all at the the treatment, an upate is not pertinent systems (minimum time of entry by required for subsequent visits mandatory requirement of heart and PA the supervising for the same wound if a lung exam) NP provider. progress note with a Diagnosis/Impression PA, For Scribes, description of the wound is Treatment Plan and documentation of NP, H&Ps must be documented for each visit. discussion of reasons for any limited Midwife authenticated at treatment plan and patient and/or and the time of family informed of the plan Medical by the Students supervising provider and
update prior to surgery must be completed by a member of the CVMC Medical Staff H&P Update: An update must be completed, by a member of the medical staff, immediately prior to a procedure requiring anesthesia indicating that the H&P was reviewed, the patient examined, and “no change” has occurred since H&P completion OR document any changes in patient condition prior to procedure requiring anesthesia. If the Observation patient converts to inpatient status and the H&P of record was completed by a dentist or podiatrist, a complete History and Physical must be completed by an MD or DO. prior to leaving the patient unit. OUTPATIENT (including Chemotherapy, Transfusions, etc.) No History and Physical Required CENTER History and Physical Joint Commission H&Ps must be done within 30 days prior to the initial visit H&P Update – Unless moderate sedation or anesthesia is used to perform the treatment, an upate is not required for subsequent visits for the same wound if a progress note with a description of the wound is documented for each visit. Dictated or handwritten Physician’s Notes Complaint History of Present Illness Relevant Past, Social, and Family Histories Review of Systems Relevant Physical Examination of all pertinent systems (minimum mandatory requirement of heart and lung exam) Diagnosis/Impression Treatment Plan and documentation of discussion of reasons for any limited treatment plan and patient and/or family informed of the plan MD, DO, oral surgeon, dentist, or podiatrist PA NP PA, NP, Midwife and Medical Students For PA, NP, Midwife and Medical Students, H&Ps must be at the time of entry by the supervising provider. For Scribes, H&Ps must be authenticated at the time of by the supervising provider and
20170130-BYLAWS-APPROVED-BOT-JAN-2017-2.docx