Required Guidelines for History & Physical

The Joint Commission (RC 01.01.01 EP 4)

History & Physical must be completed and documented within 24 hours following
admission of the patient, but prior to surgery or a procedure requiring anesthesia
services (including moderate sedation)

H&P exams performed 30 days prior to admission may be used if the following
requirements are met:

• Physician writes an update note which is written on or attached to the H&P.
• The H&P and any updates/assessments must be included in the medical record within 24 hours of admission, but prior to surgery or other procedures- whichever comes first H&P performed more than 30 days prior to admission; outpatient, observation, or outpatient surgery will not be accepted and a new H&P must be completed.

An H&P shall include the following minimal elements:

• 1. History
  • a. identifying data (e.g., name, age, sex)
  • b. chief complaint; history of present illness
  • c. medications
  • d. allergies
  • e. habits (e.g., tobacco, alcohol, other, as appropriate)
  • f. past medical and surgical history, as appropriate
  • g. relevant past social and family history, as appropriate
• 2. Physical
  • a. heart
  • b. lungsv
  • c. areas of body as appropriate to the chief complaint
  • d. laboratory results, as appropriate
  • e. diagnosis
  • f. plan
• 3. Other relevant elements–advance directives, informed consent
  • • Obstetrical records must include prenatal information
• 4. For children–an evaluation of the developmental age
• 5. The H&P must contain sufficient information to support the diagnosis or differential diagnosis, justify the treatment plan, and facilitate the care after discharge.
• 6. The H&P must be legible and documented in a manner so as to be durable and permanent.
• 7. A handwritten or transcribed H&P must be in the patient’s medical record within 24 hours of admission.