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

Video Transcription

Video Summary

Laura Dixon, an experienced nurse and attorney, discusses CMS requirements for History and Physical (H&P) documentation in hospitals, focusing on patient safety and regulatory compliance. She highlights common deficiencies found during CMS surveys, such as untimely completion, lack of updates within 30 days before surgery, absence before invasive procedures, and failure to sign off by appropriate practitioners. Dixon explains that CMS mandates an H&P within 24 hours of admission or no more than 30 days before outpatient surgeries, with specifics depending on hospital type (acute or critical access) and states permitting delegation to qualified advanced practice providers (NPs, PAs). CMS recently eased outpatient surgery requirements, allowing a pre-procedure assessment instead of a full H&P for certain healthy patients, decided by hospital medical staff policy. She emphasizes the critical need for clear bylaws and medical staff policies defining H&P responsibilities, documentation standards, delegation protocols, and update procedures. Dixon also covers scenarios like emergency surgeries where ER notes might suffice and reiterates the importance of having H&P readily available prior to surgery. Quality assurance programs should monitor compliance to prevent citations or potential termination from Medicare agreements. The session addresses practical challenges, including staff roles, legal considerations, and state law variations, providing healthcare providers with tools to ensure they meet CMS conditions, safeguard patient care, and avoid survey deficiencies.

Keywords

CMS requirements

History and Physical documentation

patient safety

regulatory compliance

hospital surveys

outpatient surgery

advanced practice providers

medical staff policies

quality assurance