History and Physicals: Meeting Hospital CoPs in 2023

Recorded Webinar | Laura A. Dixon | From: Nov 21, 2023 - To: Dec 31, 2023

CMS made a change regarding History and Physicals. Specifically, healthy outpatients may not be required to have a full history and physical. The new process for this to occur will be explained including a required policy, Medical Staff and Board approval, revised medical staff bylaws, and more. The webinar will discuss what should be in the policy.

By attending this program, you can learn what is required to be in the history and physical and how to meet compliance with both the CMS hospital conditions of participation, the Joint Commission, and DNV standards. CMS has five separate sections that address history and physicals for Acute and CAHs.

Hospitals need to ensure that hospital policies and procedures meet the H&P requirements. Medical staff by-laws must also comply with the regulations interpretive guidelines and standards. The Joint Commission and DNV standards on history and physicals will be discussed.

Information on medical records deficiencies cited by CMS for both acute and critical access hospitals will be covered. Common deficiencies will show what CMS identifies during a medical record review.

Learning Objectives:-

  • Recall that CMS has H&P requirements in the hospital conditions of participation that all hospitals that accept Medicare must follow
  • Identify Joint Commission and DNV standards on H&P
  • Describe that the hospital must have medical staff by-laws and policies that include the requirements for H&Ps
  • Discuss what hospitals must do to implement the new rule that H&Ps do not need to be done on healthy outpatients

Detailed Outline:-

  • Introduction to the CMS hospital CoP requirements
  • CMS current hospital CoP manual
  • Cited deficiencies and how to locate
  • Recent changes – overall
  • H&P in the Medical Staff section
  • Medical staff by-laws
  • 24-hour update rule and the 30-day rule
  • Updates the day of surgery or procedure requiring anesthesia services
  • Who can perform an H&P
  • When an H&P is required
  • H&P on the chart before surgery
  • Documentation in the medical record
  • H&P done by a non-credentialed practitioner
  • CMS clarification memo
  • H&P in the Medical Records section
  • H&P in surgery services
  • CoP for H&Ps in Critical Access Hospitals
  • CAH requirements and new tag numbers

The Joint Commission Standards

  • Medical staff chapter
  • Provision of care chapter standards
  • Record of care chapter standards
  • Documenting H&P
  • MS by-laws
  • FAQ on H&P
  • Qualified physician and delegation
  • Practitioners without privileges
  • Medical students doing H&P
  • H&P for outpatient procedures
  • Podiatrist doing H&P
  • H&P for outpatient procedures
  • Authentication of H&P
  • Delegation of H&P
  • FAQs and prenatal records
  • Update requirements

DNV H&P Standards

  • Medical Staff section
  • Surgical Services section
  • Medical Records section

Appendix and Resources

Who Should Attend:-

  • Chief Medical Officer
  • Chief Nursing Officer
  • OR staff and OR nurses
  • Director of HIM
  • Outpatient nurses and staff
  • Surgery nurses
  • MS staff and physicians, PAs, and NPs
  • Risk Managers
  • Compliance Officers
  • Director of Regulatory Affairs
  • Outpatient Director
  • Joint Commission/DNV Director
  • Director of Health Information Management
  • Anyone involved in ensuring compliance with the history and physical requirements from the Joint Commission, DNV, and CMS hospital conditions of participation

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