200 Hoods Lane | P.O. Box 1168 | Marblehead, MA 01945 | www.greeley.com

Consulting tel 888/749-3054 fax 781/639-0085 | Seminars tel 800/801-6661 fax 800/738-1553

Rules for the History and Physical Examination

1. Who May Perform and Document the History and Physical Exam

The History and Physical Examination shall be performed and recorded by a doctor of medicine or osteopathy, or, for patients admitted only for oral maxillofacial surgery, by an oral maxillofacial surgeon. [42CFR 482.22] (The MD/DO may delegate all or part of the physical examination and medical history to other practitioners, but the MD/DO must sign for and assume full responsibility for these activities.)

2. History and Physical Examination Timeframes and Required Updates

If a History and Physical Examination has been performed and documented within thirty (30) days of the patient’s admission to the Hospital or admission for a scheduled operative or invasive procedure, a legible copy of that history and physical examination may be used in the patient’s medical record provided that an update is performed by an licensed independent practitioner or designee with privileges to perform H & Ps and documented prior to the start of the operative procedure or, if for admission to the hospital, at the time of, or within 24 hours of admission as an inpatient. This Updated History and Physical Examination must:

(a) Address the patient’s current status and/or any changes in the patient’s status (if there are no changes in the patient’s status, this should be specifically noted);

(b) Include an appropriate physical examination of the patient to update any components of the exam that may have changed since the prior history and physical, or to address any areas where more current data is needed;

(c) Confirm that the necessity for the admission, procedure, or care is still present;

(d) Be written or otherwise recorded on, or attached to, the previous History and Physical, or written in a progress or consult note; and

(e) Be placed in the patient’s medical record prior to the operative procedure, or at the time of or within 24 hours of admission.

A. ADMISSION HISTORY AND PHYSICAL EXAMINATION

1. Compliance with Documentation Guidelines

The documentation of the admission history and physical examination shall be consistent with the current guidelines for the documentation of evaluation and management services as promulgated by the Centers for Medicare and Medicaid Services or comparable regulatory authority or as defined by the medical staff. Traditionally, the History and Physical Examination report includes the following information:

  1. Chief complaint or reason for the admission or procedure;
  2. A description of the present illness;
  3. Past medical history, including past and present diagnoses, illnesses, operations, injuries, treatment, and health risk factors;
  4. An age-appropriate social history;
  5. A pertinent family history;
  6. A review of systems;
  7. Relevant physical findings;
  8. Documentation of medical decision-making including a review of diagnostic test results; response to prior treatment; assessment, clinical impression or diagnosis; plan of care; evidence of medical necessity and appropriateness of diagnostic and/or therapeutic services; counseling provided, and coordination of care.

2. Attending Physician is Responsible for the Admission History and Physical Examination

Completion of the patient’s admission history and physical examination is the responsibility of the attending physician or his/her designee.

B. Preoperative Documentation

1. Except in an emergency, a current medical history and appropriate physical examination will be documented in the medical record prior to:

(a) All invasive procedures performed in the Hospital’s surgical suites;

(b) Certain procedures performed in the Radiology Department and Cath Lab (e.g., angiography, angioplasty, myelograms, abdominal and intrathoracic biopsy or aspiration, pacemaker and defibrillator implantation, electrophysiologic studies, and ablations); and

(c) Certain procedures performed in other treatment areas (e.g., bronchoscopy, gastrointestinal endoscopy, transesophageal echocardiography, therapeutic nerve blocks, central arterial line insertions, and elective electrical cardioversion).

2. Documentation Options

(a) Inpatient who subsequently requires surgery: These patients should already have an Admission History and Physical on their chart. The surgeon should enter a progress note or consultation note documenting the provisional diagnosis, the indications for the procedure, and any changes in the patient’s condition since the Admission History and Physical.

(b) Day/Observation Patient Surgical Admission: The attending physician must record an “Admission History and Physical Examination” as described in section A. If the Admission History and Physical Examination is performed by a physician other than the surgeon (e.g., the patient’s attending physician or a consulting physician) the surgeon should enter a pre-procedure progress note or consultation note documenting the provisional diagnosis, the indications for the procedure, and any changes in the patient’s condition since the Admission History and Physical Examination. If there are no changes in the patient’s condition, this should be specifically noted.

(c) Outpatient Surgery: The surgeon may complete a “Focused Preoperative History and Physical Form” as approved by the Medical Executive Committee. If the Focused Preoperative History and Physical was performed prior to the day of the procedure the surgeon must on the day of surgery note any changes in the patient’s condition since the Focused History and Physical Examination. If there are no changes in the patient’s condition, this should be specifically noted.

(d) Outpatient Surgery Patient Subsequently Admitted to Observation/Inpatient: The surgeon should have already completed a “Focused Preoperative History and Physical Form.” Upon admission, an update describing the reason(s) for the admission must be documented within 24 hours by the attending physician or his/her designee, specifically addressing any changes in the patient’s condition since completion of the Focused Preoperative History and Physical Form.

June, 2005

John R. Rosing, MHA, FACHE

The Greeley Company