History and Physicals: Meeting Hospital CoPs in 2024-History and Physicals final presentation

History and Physicals final presentation
Pdf Summary
The document provides a comprehensive overview of the standards and procedures regarding History and Physicals (H&P) for healthcare organizations, as stipulated by CMS (Centers for Medicare & Medicaid Services), TJC (The Joint Commission), and DNV (Det Norske Veritas). Laura A. Dixon, Esq., a professional in healthcare risk education and consulting, outlines the regulations, guidelines, and implications for compliance in healthcare settings.<br /><br />Key sections of the document include:<br />1. **Regulatory Framework**: The document describes how regulations are published in the Federal Register, followed by CMS issuing transmittals, developing interpretive guidelines, and updating the hospital Conditions of Participation (CoP) manual.<br />2. **Keeping Up with Changes**: It emphasizes the importance of subscribing to updates from Federal and CMS sources to stay current.<br />3. **Deficiency Reports**: Provides an overview of common deficiencies in H&P procedures, such as surgeons not updating records, outdated H&Ps, and issues with documentation prior to surgeries.<br />4. **2019 CMS Updates**: Combines several laws into one and allows flexibility for healthy outpatients in hospitals and Ambulatory Surgical Centers (ASCs) to have pre-surgery assessments instead of full H&Ps.<br />5. **Requirements and Policies**: Highlights the need for a medical staff policy on H&Ps for outpatient surgeries, considering factors like patient age, comorbidities, national guidelines, and applicable state laws.<br />6. **Changes in Documenting H&Ps**: Discusses the procedures for ensuring H&Ps are updated and documented timely, emphasizing the examination of any changes in a patient's condition before surgery.<br />7. **Survey Procedure**: Guidance for surveyors on verifying compliance with H&P requirements during reviews of medical records.<br />8. **Delegation and Responsibility**: Clarifies who can perform and update H&Ps, including physicians, qualified licensed practitioners, and midlevel providers like Physician Assistants (PAs) and Nurse Practitioners (NPs), with specific state law allowances.<br />9. **The Joint Commission and DNV Standards**: Reviews specifics of TJC and DNV standards regarding the completion, documentation, and update of H&Ps.<br />10. **Key Takeaways**: Advises healthcare organizations to ensure their medical staff bylaws and policies are clearly defined regarding who can perform H&Ps, the required content, and procedures when H&Ps are missing before surgeries.<br /><br />Overall, the document stresses the importance of proper documentation, timely updates, adherence to regulatory standards, and the implementation of robust policies to ensure compliance and patient safety.
Keywords
History and Physicals
CMS
TJC
DNV
Healthcare Compliance
Regulatory Framework
Deficiency Reports
2019 CMS Updates
Survey Procedure
Medical Staff Policies