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Measures added to ensure H&P completion

27 Feb 2022

Outdated H&Ps flagged; find documentation rules on tip sheet

By: Deni Hoover, chief surgical services officer, and Angela Anderson, DO, surgical services medical director

We’ve noticed an increase in outdated or missing documentation recently, in completing pre-operative/pre-procedure chart review of History and Physical information.

The requirement that an updated H&P (within 30 days of the procedure date) must be completed before a patient can be taken to the operating/procedure room is not new. These standards are from CMS, also surveyed by The Joint Commission and included in Salem Health medical staff bylaws.

The root of this requirement is patient safety — an updated H&P the care team can access immediately to confirm planned procedures and patient-specific factors is critical to patient care.

As a result, we’ve added these measures to close these gaps:

  • Pre-Surgical Screening identifies patients with outdated H&Ps (>30 days old) who have a scheduled procedure, and will try to contact the scheduling physician by email to alert them of the outdated document.
  • The prep nurse will remind the performing physician on the day of the procedure to let them know they need to complete a full H&P before the anesthesiologist will take the patient into the OR or procedure room. This cannot be dictated on the morning of the procedure, due to the delay in waiting for transcription. 
  • If an H&P is missed, you will be notified by HIM as a chart deficiency, and may have a follow up conversation with leaders to work on how to avoid this error.

The regulatory team created this tip sheet to show these requirements in a concise document. Here is the link to the medical staff bylaws that outlines the same requirements in Appendix A, pages 19-21.  

We appreciate your continued partnership and commitment to patient safety.