Ms. RHIT is analyzing and assembling a patient's record and notices that a copy of a history and physical from the attending physician's office was used in the record instead of an inpatient history and physical. The office H&P was completed on January 2 (this year), and the patient was admitted to the hospital on January 5 (this year); the office H&P was placed on the record at the time of admission. According to Medicare CoP regulations, the office H&P is:
A) acceptable, as the H&P for this admission because it was placed on the record within 24 hours.
B) acceptable, as the H&P for this admission because it was completed no more than seven days prior to admission
C) unacceptable, because only a newly documented inpatient H&P is acceptable
D) unacceptable, because the office H&P was not completed within 24 hours prior to admission.
Question 2
Molly Mapes was admitted to Sunny Valley Hospital on January 22 (this year) for pneumonia. The history and physical examination (H&P) was placed on the record January 24 (this year). Which of the following statements is true, based on Joint Commission standards?
A) The record is in compliance, as the H&P needs to be completed within 48 hours.
B) The record is in compliance, as the H&P needs to be completed within 72 hours.
C) The record is not in compliance, as the H&P needs to be completed within 24 hours.
D) The record is not in compliance, as the H&P needs to be completed within 12 hours.
The nurse needs to note the source of the patient health history
It is important to act concerned when a patient is upset.
Patient health history form.
Amyloid plaques (stained blue) in the brain of a deceased patient who had Alzheimer’s disease.
An overlapping record extends back thousands of years of tree ring width