Number: MS -012 Effective Date: September 26, 2016 BO Revised:11/28/2016; 11/27/2017; 1/22/2018; 8/27/2018 CaroMont Regional Medical Center Author: Approved: Patrick Russo, MD, Chief-of-Staff Authorized: Todd Davis, MD, EVP, GMO MEDICAL STAFF MEDICAL RECORD POLICY 1. REQUIRED COMPONENTS OF THE MEDICAL RECORD The medical record shall include information to support the patient's diagnosis and condition, justify the patient's care, treatment and services, and document the course and result of the patient's care, and services to promote continuity of care among providers. The components may consist of the following: identification data, history and physical examination, consultations, clinical laboratory findings, radiology reports, procedure and anesthesia consents, medical or surgical treatment, operative report, pathological findings, progress notes, final diagnoses, condition on discharge, autopsy report when performed, other pertinent information and discharge summary. 2. ADMISSION HISTORY AND PHYSICAL EXAMINATION FOR HOSPITAL CARE Please refer to CaroMont Regional Medical Center Medical Staff Bylaws, Section 12.E. A. The history and physical examination (H&P), when required, shall be performed and recorded by a physician, dentist, podiatrist, or privileged practitioner who has an active NC license and has been granted privileges by the hospital. The H&P is the responsibility of the attending physician or designee. Oral surgeons, dentists, and podiatrists are responsible for the history and physical examination pertinent to their area of specialty. B. If a physician has delegated the responsibility of completing or updating an H&P to a privileged practitioner who has been granted privileges to do H&Ps, the H&P and/or update must be countersigned by the supervisor physician within 30 days after discharge to complete the medi_cal record. C. An H&P is required for all inpatient and observation admissions, prior to outpatients undergoing invasive procedures in the hospital's surgical suites, certain procedures performed in Imaging Services and Cath Lab, and other areas that perform invasive procedures. See Table below for details when an H&P is required. D. A medical history and appropriate physical examination must be completed and documented in the medical record no more than thirty (30) days before or within twenty-four (24) hours after a hospital inpatient or observation admission, but prior to an operative or high-risk procedure requiring anesthesia services is performed. E. H&P UPDATE: For an H&P that was completed within 30 days prior to inpatient or observation admission, an update documenting examination of the patient and any changes in the patient's condition is completed within 24 hours after admission, but prior to an operative or high-risk procedure requiring moderate sedation or anesthesia services. The update note must include language such as "Patient examined and no changes" or changes identified should be documented. F. The H&P time requirement is not required prior to an emergent situation but should be documented as soon as possible after the procedure is completed if the patient requires inpatient or observation admission. G. The H&P performed on admission of the patient is applicable to the entire hospital stay and a new H&P does not need to be performed if a patient has a subsequent procedure, provided progress notes or consultation reports indicate the patient's updated status prior to the procedure. H. CONTENT OF HISTORY AND PHYSICAL: History and Physical examination reports should include at a minimum, the following items: Chief Complaint, History of Present Illness, relevant Past History, relevant Review of Systems, relevant Physical Examination, impression or Diagnosis, and Plan. Short History and Physical forms may be used as approved by the appropriate Service Lines. I. NEWBORN INFANTS An admission physical examination shall be completed and recorded within twenty-four (24) hours after birth and the infant shall be examined daily during hospitalization. An infant may be discharged as long as he or she has been examined on that day and the discharge order is written. It is not necessary for the discharge summary to be complete if another note already exists on that day. When a newborn expires before an admission physical examination has been completed, the on call pediatrician or neonatologist or their designated privileged practitioner should document at least a progress note indicating the circumstances related to the infant's birth and death and neither physical examination nor discharge summary is required. J, DOCUMENTATION FOR OUTPATIENT BLOOD TRANSFUSIONS AND IV 2 MEDICATION INFUSIONS For therapeutic outpatient blood transfusions and IV medication administration, the physician must provide an order for the treatment and the reason (diagnosis) for treatment. K. OBSTETRICAL TRIAGE DOCUMENTATION Patients seen in the Obstetrics Triage area with a stay less than 4 hours do not require a complete history and physical examination. L. TABLE OF ADMISSION TYPES, STATUS AND REQUIREMENTS Invasive/High Risk Procedures are defined as procedures done outside operating room that carry an inherent high risk to the patient. Examples of Invasive/High Risk Procedures are: Arterial Angiography and/or Embolization Transesophageal Echocardiography Cardioversion Endoscopy Bronchoscopy Uterine Fibroid Embolization Soft Tissue and Tumor Thermal Ablation TIPS De Novo Percutaneous Transhepatic Biliary Drain Placement Vertebroplasty/Kyphoplasty Pacemaker Insertion AICD Insertion Epidural Steroid Injections Facet Injections Invasive/Low Risk Procedures are defined as procedures done outside the operating room that carry an inherent low risk to the patient. Examples of Invasive/Low Risk Procedures are: Chest Tube Insertions Central Lines Insertions Arterial Line insertions Needle aspiration/biopsy Port Placement Percutaneous Drain Placement Lumbar Punctures Paracentesis Thoracentesis Drain/Line Exchange Chemotherapy Infusions Myelograms 3 Arthrograms Urodynamic Studies Non-invasive Diagnostic Studies are defined as studies done to aid in diagnosis of pathology that do not require a procedure. Examples of Non-invasive Diagnostic Studies are: CT Scans MRI Scans EEG Type of admission Admission status H&P Requirement Medical Admission - non- Inpatient or Observation H&P recorded within 24 surgical/procedural, such as hours after admission. If pneumonia, heart failure, H&P is performed within 30 etc. days prior to admission it must be updated within 24 hours after admission. Update must include that patient is examined, and note any changes or that no changes exist. 4 Surgical admission - Inpatient, Observation, H&P recorded within 24 admission for surgical Outpatient Surgery at any hours after admission. If treatment of a disease or operating suite location H&P is performed within 30 treatment days prior to admission it must be updated prior to an operative or high-risk procedure requiring anesthesia. Update must include that patient is examined, and note any changes or that no changes exist. Emergent cases do not require H&P prior to the procedure but must be completed as soon as possible after the procedure is completed and the physician shall record the pre-procedural diagnosis prior to the procedure performed. 5 OB Delivery Inpatient H&P recorded within 24 hours after admission. If an H&P is performed within 30 days prior to admission it must be updated within 24 hours after admission but must be updated prior to an operative or high-risk procedure requiring anesthesia. Update must include that patient is examined, and note any changes or that no changes exist. Emergent cases do not require H&P prior to the procedure but must be completed as soon as possible after the procedure is completed and the physician shall record the pre-procedural diagnosis prior to the procedure performed. OB Triage Observation or Outpatient No H&P required unless stay exceeds 4 hours Newborn Inpatient Admission physical examination completed within 24 hours after birth. If an infant expires before admission physical examination completed, a progress note indicating the circumstances related to the infant's birth and death is required to be documented. Invasive/High Risk Inpatient, Observation, or H&P recorded within 24 Procedures requiring Outpatient hours after admission. If an moderate sedation or H&P is performed within 30 anesthesia services. days prior to admission it must be updated within 24 6 hours after admission but must be updated prior to an operative or high-risk procedure requiring anesthesia. Update must include that patient is examined, and note any changes or that no changes exist. Emergent cases do not require H&P prior to the procedure but must be completed as soon as possible after the procedure is completed and the physician shall record the pre-procedural diagnosis prior to the procedure performed. Invasive/Low-Risk Performed in any setting or No H&P required. Procedures or Non-Invasive location such as Imaging, at Diagnostic studies with or patient's bedside When moderate sedation without moderate sedation or anesthesia services are or anesthesia services required for diagnostic studies or procedures in this category, a pre- anesthesia assessment is required to be performed by the practitioner administering anesthesia and includes ASA classification, airway assessment, heart, lungs, and mental status assessment. Emergency Department Emergency Department No H&P required prior to procedures with moderate the sedation