History and Physicals: Meeting Hospital CoPs in 2025 (W5030)-History and Physicals: Meeting Hospital CoPs in 2025 Presentation

History and Physicals: Meeting Hospital CoPs in 2025 Presentation

Pdf Summary

This comprehensive presentation by Laura A. Dixon, Esq., BS, JD, RN, CPHRM, focuses on 2025 CMS Conditions of Participation concerning History and Physicals (H&P) for acute hospitals, critical access hospitals (CAHs), and ambulatory surgery centers (ASCs). It covers regulatory requirements, survey procedures, deficiencies, and best practices to ensure compliance.<br /><br />Key points include CMS mandates that all patients undergoing surgery or certain procedures must have an H&P performed and documented either within 30 days before surgery (if outpatient) or within 24 hours after admission for inpatients. Updates to H&Ps are required if the original is older than 30 days or if there are changes in patient condition prior to surgery. For healthy outpatients, CMS allows flexibility to substitute a less comprehensive pre-procedure or pre-surgery assessment instead of a full H&P, although this exception does not currently apply to CAHs.<br /><br />Medical staff bylaws must address H&P policies, including who may perform the H&P (physicians, PAs, or NPs if state law permits), delegation processes, required content, and timing. Hospitals must document these policies clearly and ensure all H&Ps or assessments are present and current in patient charts before surgery or procedures requiring anesthesia. Updates may be completed through progress notes, stamps, or other verifiable means.<br /><br />Surveyors will review medical staff bylaws, patient records, and credentialing to verify compliance. Deficiencies commonly include missing H&Ps, outdated or incomplete documentation, lack of attending physician sign-off on H&Ps performed by allied health professionals, and failure to update H&Ps prior to surgery.<br /><br />The presentation includes case discussions highlighting the importance of strict criteria for outpatient surgeries, such as patient selection based on age, comorbidities, and anesthesia levels, with clear policies ensuring H&P validity.<br /><br />Overall, the material emphasizes thorough policy development, regular quality assurance, and adherence to CMS standards to prevent deficiencies and ensure patient safety and regulatory compliance across hospital and surgery center settings.

Keywords

CMS Conditions of Participation 2025

History and Physical (H&P) requirements

acute hospitals compliance

critical access hospitals (CAHs)

ambulatory surgery centers (ASCs)

pre-surgery documentation

medical staff bylaws

survey procedures and deficiencies

patient safety regulations

quality assurance in healthcare