When is a History & Physical (H&P) Exam Required?

When is an H&P Exam Required?

When is an H&P exam required? For example, let’s say a provider is performing a thoracentesis in the endo suite vs inpatient bedside and is NOT using procedural sedation (just local). Is an H&P update required before the procedure if the provider is privileged and credentialed appropriately?

The Answer Depends on Patient Status

It depends on whether the patient is an inpatient or outpatient.  If this is an inpatient and not the first day of admission, you do not need to update the H&P. This is because the patient had a new H&P on admission and the progress notes during the admission serve as the update.

If the patient is an outpatient, then you are in a grey area where you must define which procedures are risky enough to require an H&P and then update it.  Your medical staff determines when you need a full H&P and the minimum elements for exam.  If the H&P is required, then the update to the H&P is also required if the H&P is not done on the day of the procedure prior to the procedure.

MS.01.01.01, EP 38 is a newish standard that allows you to determine which outpatient procedures require an H&P and which just need an “assessment.”  We recommend reviewing the language inside this element of performance.

Procedure Documentation Checklist

We would love to share our Procedure Documentation Checklist Inpatient & Outpatient job aide with you.  It needs to be customized for each hospital that uses it, but this easy-to-use one-page guide will help your staff determine when is an H&P exam required with questions such as:    

• Do I need an H&P for X procedure? 
• Do I need a post anesthesia assessment Y procedure?

…and more.

This job aide allows you to provide the guard rails of what you define as a minor procedure, invasive procedure, surgery, etc.  Staff then get to interpret which category the procedure they are questioning falls into.

Patton Healthcare Consulting

Patton Healthcare Consulting provides a complete range of Joint Commission and CMS Compliance Assistance and a full range of pre-survey and post survey services.

We serve more than 400 hospitals, behavioral health care organizations, ambulatory clinics and home care companies nationwide—hospitals ranging from critical access hospitals to the largest health systems. Contact us at (888) PHC-INC1 for more information.