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.
Measuring Patient Height
Nursing history for female genetalia and reproductive tract assessment
Apply direct pressure to the patient’s wound.
Walkers help the patient ambulate safely.
Pneumonia patient’s chest x-ray. Note the irregular areas of density.
Patient Physical Status Classification