History and Physicals: Meeting Hospital CoPs in 2024-HistoryandPhysicals2024LMSRecording

Video Transcription

Video Summary

Laura Dixon, a director in patient safety and risk management, introduces a program on the importance of history and physicals (H&P) for patient care. Laura's extensive background includes roles at Kaiser Permanente, COPEC, and the Doctors Company, coupled with her credentials as a registered nurse and attorney. <br /><br />The session highlights the significance of H&Ps, especially during CMS surveys. Laura stresses the necessity of having up-to-date H&P records for all patients undergoing surgery or procedures requiring anesthesia, adhering to a timeframe of no older than 30 days and within 24 hours of admission. She discusses various regulatory scenarios, such as the acceptability of outpatient assessments for healthy patients in lieu of full H&Ps, provided specific criteria are met. Laura covers state laws, hospital bylaws, and the importance of thorough documentation.<br /><br />Several key points include:<br />- H&P must be updated and in the record before surgery.<br />- In emergencies, progress notes with crucial patient information can suffice.<br />- Policies allow for delegation of H&P tasks to advanced practice providers under supervision.<br />- Practitioners must ensure entries are documented, signed, and dated.<br /><br />The session addresses how CMS surveyors will scrutinize compliance with these guidelines during audits. Laura also covers related sections in medical records and surgical services documentation, outlining deficiencies and potential updates to regulatory practices.<br /><br />Audience questions clarify nuances, such as the use of ER notes by podiatrists and the role of medical students and residents in H&P completion. Joint commission standards and DNV (Det Norske Veritas) accreditation specifics are also discussed, reiterating similar principles with slight variations.<br /><br />In summary, the session advocates for meticulous H&P practices to ensure compliance and patient safety, emphasizing the need for clear policies and thorough documentation.

Keywords

Laura Dixon

patient safety

risk management

history and physicals

H&P

CMS surveys

surgery

anesthesia

documentation

regulatory compliance

medical records

hospital bylaws

advanced practice providers