prior to leaving the patient unit. EMERGENCY DEPARTMENT PATIENTS Emergency Completed upon discharge from Dictated or Emergency Complaint MD/DO For PA, NP, Department Report the ED handwritten Department History of Present Illness PA Midwife and Report Relevant Past, Social, and Family NP Medical – Joint Commission dictated Histories Midwife Students, H&Ps Medicare ED Review of Relevant Systems PA, NP, must be Conditions of Physician Physical Exam of the systems Midwife at the Participation Record pertinent to the chief complaint to and time of entry by – handwritten include vital signs Medical the supervising Diagnosis Students provider. Treatment Plan and documentation of Scribe** For Scribes, discussion of reasons for any limited H&Ps must be treatment plan and patient and/or authenticated at family informed of the plan the time of entry Documentation of what is to be done by the as an inpatient that cannot be done as supervising an outpatient, how outpatient therapy provider and failed, and reasons why problems prior to leaving were not resolved during previous or the patient unit. recent admissions for the same diagnosis HOSPICE PATIENTS History and Physical History and Physical from the acute See Inpatient on page ix. inpatient stay will be copied to the Hospice record. OB PATIENTS History and Physical Within 24 hours of admission Dictated or OB H&P Chief Complaint MD, DO Supervising Prior to performing a cesarean handwritten Physician History of Present Illness Midwife physician must Joint Commission section Progress Relevant Past, Social, and Family Resident co-sign all H&Ps Medicare H&P Update: An update must Notes Histories PA, NP, performed and Conditions of be completed, by a member of Dictated Review of Relevant systems Midwife documented by Participation the medical staff, immediately Prenatal Physical Exam of all pertinent systems and a resident. For prior to a procedure requiring Record (minimum mandatory requirement of Medical PA, NP, Midwife anesthesia indicating that the must be heart and lung exam) to include vital Students and Medical H&P was reviewed, the patient on the signs, and labor progress Scribe** Students, H&Ps examined, and change” inpatient Admitting/Provisional Diagnosis or must be “no has occurred since H&P record Impression at the completion OR document any Treatment Plan and documentation of time of entry by changes in patient condition discussion of reasons for limited the supervising prior to procedure requiring treatment plan and patient and/or provider. anesthesia. family informed of the plan
prior to leaving the patient unit. EMERGENCY DEPARTMENT PATIENTS Emergency Department Report Joint Commission Medicare Conditions of Participation Completed upon discharge from the ED Dictated or handwritten Emergency Department Report – dictated ED Physician Record – handwritten Complaint History of Present Illness Relevant Past, Social, and Family Histories Review of Relevant Systems Physical Exam of the systems pertinent to the chief complaint to include vital signs Diagnosis Treatment Plan and documentation of discussion of reasons for any limited treatment plan and patient and/or family informed of the plan Documentation of what is to be done as an inpatient that cannot be done as an outpatient, how outpatient therapy failed, and reasons why problems were not resolved during previous or recent admissions for the same diagnosis MD/DO PA NP Midwife PA, NP, Midwife and Medical Students Scribe** 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 entry by the supervising provider and prior to leaving the patient unit. HOSPICE PATIENTS History and Physical History and Physical from the acute inpatient stay will be copied to the Hospice record. See Inpatient on page ix. OB PATIENTS History and Physical Joint Commission Medicare Conditions of Participation Within 24 hours of admission Prior to performing a cesarean section 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. Dictated or handwritten OB H&P Physician Progress Notes Dictated Prenatal Record must be on the inpatient record 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, and labor progress Admitting/Provisional Diagnosis or Impression Treatment Plan and documentation of discussion of reasons for limited treatment plan and patient and/or family informed of the plan MD, DO Midwife Resident PA, NP, Midwife and Medical Students Scribe** Supervising physician must co-sign all H&Ps performed and documented by a resident. For PA, NP, Midwife and Medical Students, H&Ps must be at the time of entry by the supervising provider.
20170130-BYLAWS-APPROVED-BOT-JAN-2017-2.docx