Imagine that you are the HIM Supervisor over the record completion area in a multi-facility healthcare system. The HIM Director has asked you to provide information about the documentation requirements for various record types (Acute, Outpatient, LTC, Rehab, and Behavioral health) for the History and Physical (H&P). You must research The Joint Commission, the CMS Conditions of Participations (COPs), CARF, and your state’s law. Complete the table below that compares the H&P requirements for all record types. Acute Care Outpatient Long term care Rehab Behavior Health

Introduction

Documentation is an essential aspect of healthcare, as it provides a comprehensive record of a patient’s medical history, treatment, and outcomes. In particular, the History and Physical (H&P) is a critical document that provides crucial information about a patient’s current condition, medical history, and physical examination findings. The HIM Supervisor in a multi-facility healthcare system has been tasked with researching and providing information on the documentation requirements for various record types, including Acute Care, Outpatient, Long-term care (LTC), Rehab, and Behavioral Health. In order to fulfill this task, it is necessary to examine the documentation requirements outlined by The Joint Commission, the CMS Conditions of Participations (COPs), CARF, and relevant state laws.

Acute Care

In the context of Acute Care, the H&P documentation requirements are guided by various regulatory bodies, including The Joint Commission, CMS, CARF, and the state’s law. The Joint Commission, which accredits and certifies healthcare organizations, requires that an H&P be completed and documented within 24 hours of admission or before surgery, as stated in its Hospital Accreditation Standards (The Joint Commission, 2021). Additionally, the CMS Conditions of Participations (COPs) mandate that an H&P be completed within 24 hours of inpatient admission, as specified in the Hospital’s Conditions of Participation (CMS, 2021). However, it is important to note that specific state laws may impose stricter requirements or additional documentation guidelines that need to be adhered to.

Outpatient

Unlike Acute Care settings, Outpatient facilities have different requirements for H&P documentation. The Joint Commission and CARF provide guidance for various areas within the out-of-hospital setting. The Joint Commission states in its Ambulatory Care Accreditation Standards that H&P documentation is required for surgical and invasive procedures, and the completion timeline should be consistent with the organization’s protocol and the nature of the procedure (The Joint Commission, 2021). CARF, an international accrediting body for rehabilitation services, does not specifically require an H&P for outpatient services but emphasizes the importance of comprehensive evaluation and assessment for treatment planning (CARF, 2021). Additionally, it is essential to review state laws to determine if any specific requirements exist for outpatient settings.

Long term care (LTC)

In Long-term care facilities, H&P documentation is crucial for resident care planning and ensuring the provision of appropriate services. The Joint Commission, in its Nursing Care Center Accreditation Standards, requires that an H&P be completed within seven days of admission, unless the resident was recently admitted to another healthcare facility or there is a proper reason for the delay (The Joint Commission, 2021). CMS also outlines requirements for LTC facilities in its State Operations Manual, stating that an H&P must be completed within seven days of admission unless a physician or other qualified practitioner has conducted a comprehensive assessment within the past 30 days (CMS, 2021). State laws may further specify additional requirements or timeframes for LTC facilities.

Rehab

In Rehabilitation settings, comprehensive assessment and documentation play a pivotal role in the development and implementation of an individualized treatment plan. CARF, being the leading accrediting body for rehabilitation services, provides specific guidelines for H&P documentation in its Medical Rehabilitation Standards (CARF, 2021). CARF requires a comprehensive medical history and physical examination to be conducted promptly upon admission, either by a physician or another qualified healthcare professional (CARF, 2021). The documentation should include a summary of findings relevant to the diagnosis and treatment, as well as assessments of various areas, such as mobility, communication, and cognition (CARF, 2021). However, it is important to review state laws as they may impose additional requirements or timelines specific to rehab settings.

Behavioral Health

In Behavioral Health settings, comprehensive documentation supports the provision of appropriate mental health services and ensures continuity of care. The Joint Commission’s Behavioral Health Care Accreditation Standards require that an H&P be completed within 24 hours of admission, unless a comprehensive assessment has been conducted within the past 72 hours (The Joint Commission, 2021). Additionally, CMS’s Conditions of Participations for Psychiatric Hospitals stipulate that an H&P should be completed within 24 hours of admission or before surgery if applicable (CMS, 2021). State laws may provide further guidance or requirements specific to behavioral health settings.

Conclusion

In conclusion, the documentation requirements for the History and Physical (H&P) vary across different healthcare settings. While Acute Care facilities have specific timelines mandated by The Joint Commission and CMS, out-of-hospital settings such as Outpatient, LTC, Rehab, and Behavioral Health may have differing requirements in accordance with accrediting bodies or state laws. It is essential for HIM supervisors and healthcare professionals to be aware of these requirements and ensure compliance to provide high-quality care and maintain regulatory standards.