History and Physical – Update Requirements

Posted on Feb 4, 2019 in Announcements | 0 comments

Joint Commission and CMS will have increased focus on the medical record review portion of the survey.   You can expect additional review in the area of History and Physicals among additional area’s outlines below:

You can expect additional review on the following topics:

  • Admitting diagnosis
  • H&P
  • Notes and reports necessary to monitor condition
  • Care plan
  • Patient Rights
  • Informed consent
  • Advanced directives
  • Notification of admission
  • Visitation rights
  • Medication administration
  • Medical record justification for care
  • Nutritional needs
  • DC planning
  • DC summary
  • List of home health agencies/SNFs given if referred
  • Information forwarded to next provider of care
  • Final diagnosis
  • Consultation reports
  • Complications
  • Pre/post anesthesia assessments and Intraop care
  • Suicide assessment
  • Complaint resolution
  • Restraints and seclusion
  • Deaths (including organ procurement policies followed)
  • Notification of infectious blood, if applicable

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