History and Physical Surgical H&P must be done Dictated or Physician’s Chief Complaint MD, DO, Supervising within 30 days prior to handwritten Progress History of Present Illness oral physician must Joint Commission procedure and patient Notes Relevant Past, Social, and Family surgeon, co-sign all H&Ps Medicare reassessed the day of surgery Physician’s Histories dentist, or performed and Conditions of if it is a surgical emergency, office notes Review of Relevant Systems podiatrist documented by Participation procedure may be performed Transcribed Physical Exam of all pertinent systems Resident a resident. For without an H&P if the surgeon report (minimum mandatory requirement of PA PA, NP and documents pre-op diagnosis, heart and lung exam) to include vital NP Medical pertinent physical findings and signs, PA, NP and Students, H&Ps exam of heart and lungs prior Admitting/Provisional Diagnosis and Medical must be to the induction of anesthesia Impression Students at the H&Ps may be completed by a Treatment Plan and documentation of Scribe** time of entry by physician licensed to practice discussion of reasons for any limited the supervising in NC but not a member of the treatment plan and patient and/or provider. medical staff; however the family informed of the plan For Scribes, update prior to surgery must H&Ps must be be completed by a member of authenticated at the CVMC Medical Staff the time of the H&P Update: An update by the : must be completed, by a supervising member of the medical provider and immediately prior to a prior to leaving procedure requiring anesthesia the patient unit. 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 Same Day Surgery 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. NONOPERATIVE INVASIVE PROCEDURES (i.e. CARDIAC CATH, TEE, STEROID INJECTIONS, MYELOGRAM, ANGIOPLASTY, etc., as defined in PC-38) History and Physical Non-operative invasive Dictated or Physician’s Chief Complaint MD, DO, Supervising LIP procedure H&Ps must be done handwritten Progress History of Present Illness oral must co-sign all Joint Commission within 30 days prior and the Notes Relevant Past, Social, and Family surgeon, H&Ps performed Histories and
History and Physical Joint Commission Medicare Conditions of Participation Surgical H&P must be done within 30 days prior to procedure and patient reassessed the day of surgery if it is a surgical emergency, procedure may be performed without an H&P if the surgeon documents pre-op diagnosis, pertinent physical findings and exam of heart and lungs prior to the induction of anesthesia H&Ps may be completed by a physician licensed to practice in NC but not a member of the medical staff; however the 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 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 Same Day Surgery 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. Dictated or handwritten Physician’s Progress Notes Physician’s office notes Transcribed report Chief Complaint History of Present Illness Relevant Past, Social, and Family Histories Review of Relevant Systems Physical Exam of all pertinent systems (minimum mandatory requirement of heart and lung exam) to include vital signs, Admitting/Provisional Diagnosis and 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 Resident PA NP PA, NP and Medical Students Scribe** Supervising physician must co-sign all H&Ps performed and documented by a resident. For PA, NP 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 the by the supervising provider and prior to leaving the patient unit. NONOPERATIVE INVASIVE PROCEDURES (i.e. CARDIAC CATH, TEE, STEROID INJECTIONS, MYELOGRAM, ANGIOPLASTY, etc., as defined in PC-38) History and Physical Joint Commission Non-operative invasive procedure H&Ps must be done within 30 days prior and the Dictated or handwritten Physician’s Progress Notes Chief Complaint History of Present Illness Relevant Past, Social, and Family Histories MD, DO, oral surgeon, Supervising LIP must co-sign all H&Ps performed and
20170130-BYLAWS-APPROVED-BOT-JAN-2017-2.docx