Anesthesiology Assessment

Question:

Currently, our anesthesiologists are completing the anesthesiology assessment, not the H&P.   The providers take the anesthesiology assessment and turn this into their H&P (signing & updating just prior to surgery).  

Is this process permissible, if anesthesiology is credentialed to complete an H&P?  Or, as these are two separate documents, and the timing varies also, this process would be non-compliant even if anesthesiologists were credentialed to complete the H&P?   

Also, if all the elements were the same or the surgeon made the APP note valid by making it complete – adding HPI, etc., would this be compliant?

Answer:

The complete H&P and the update to the H&P are two different documents.  If the full H&P is done on the day of the procedure, prior to the procedure, you do not need the update to the H&P. If the H&P was complete anywhere from one day to 30 days prior to the procedure you need the update to the H&P. 

Some hospitals have authorized the anesthesiologists to perform the H&P update. If you have an anesthesia provider conduct the full H&P that is allowable if they have privileges to do that and it is acceptable in your bylaws.  The surgeon cannot sign an H&P done by an anesthesia provider to make it the surgeons H&P.