Rasmussen Medical Center
Policy: Health Record Documentation Requirements
Approval Date: xx/xx/xxxx
Policy Group: Medical Staff Bylaws
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All medical staff and health care providers shall:
History & Physical
1. A complete history and physical examination shall, in all cases be done no more than 7 days before or 24 hours after the admission of a patient. Physical examinations may be used from the previous hospitalization if the examination was within 30 days. A physical examination may be accepted from a physician’s office if the examination was within 30 days and meets the standards as defined by hospital policy and procedure. If the patient was transferred from another hospital, the physical examination may be accepted if the examination was done within 30 days, provided they are updated within 24 hours of admission or registration by the attending physician. In the above three cases, the attending physician must validate the examination in the medical record (on the physical exam) by noting that there are no significant findings or changes and signs and dates the report.
Guidelines for contents of a complete History & Physical include:
a. The Emergency Room documentation form may not be used as a History and Physical.
b. A complete history and physical examination shall be recorded before the time stated for operation or the operation shall be canceled unless the attending surgeon indicates it is an emergency procedure.
c. If the complete history and physical was dictated shortly before the operation, but not yet transcribed, the surgeon/physician will document that the history and physical has been dictated. A short History & Physical can be used for procedures using procedure/moderate sedation. No History & Physical is required for procedures using local sedation.
d. The following procedures are considered invasive and must have an History & Physical:
i. Main OR procedures ii. Ambulatory Surgeries iii. C-section deliveries/tubal ligations iv. Endoscopies
v. Cardioversions
e. The prenatal record may be substituted for a history and physical but an interval admission note must be documented that includes pertinent additions to the history and subsequent changes in the physical findings. In the event a prenatal record is not present, a complete history and physical must be provided.
f. Histories and Physicals completed by a physician assistant or nurse practitioner will be counter-authenticated by their supervising physician.
i. Responsibility for History & Physical – The attending medical staff member is responsible for the History & Physical, unless it was already performed by the admitting medical staff member. History & Physical’s performed prior to admission by a practitioner not on the medical staff are acceptable provided that they are updated timely by the attending physician. Dentists and podiatrists are responsible for the part of their patients' History & Physical that relates to dentistry or podiatry, in addition to the medical history & physical
g. Guidelines for H&P
i. Medical history ii. Chief complaint iii. History of the current illness, including, when appropriate, assessment of emotional, behavioral and social status iv. Relevant past medical, family and/or social history appropriate to the patient's age.
v. Review of body systems. vi. A list of current medications and dosages. vii. Any known allergies including past medication reactions and biological allergies viii. Existing co-morbid conditions ix. Physical examination: current physical assessment
x. Provisional diagnosis: statement of the conclusions or impressions drawn from the medical history and physical examination xi. Initial plan: Statement of the course of action planned for the patient while in the Medical Center.

Operative Report
1. An Operative report include:
a. Post-operative diagnosis
b. A detailed account of the findings
c. Technical procedures used
d. Specimens removed
e. Estimated blood loss
f. Name of the primary performing practitioner and any assistants
g. The full report must be documented immediately, as well as the recording of a post-operative progress note to be made available in the record after the procedure providing sufficient and pertinent information for use by any practitioner who is required to attend the patient.
C. A post-operative progress note will be documented immediately after surgery to include the post op diagnosis, surgeon, estimated blood loss, specimen(s), and procedure done.

Discharge Summaries 1. All discharge summaries must be documented and dictated on all medical records within 14 days after patients discharge. All summaries must be authenticated by responsible physician. 2. Physician assistants and nurse practitioners may dictate or document discharge summaries. These must be counter-authenticated by the physician. 3. Guidelines for Discharge Summary
i. Reason for hospitalization ii. Concise summary of diagnoses including any complications or co-morbidity factors iii. Hospital course, including significant findings iv. Procedures performed and treatment rendered
v. Patient’s condition on discharge (describing limitations) vi. Patients/Family instructions for continued care and/or follow-up 4. A final progress note may be used in place of a formal discharge summary for inpatient stays less than 48 hours, observations, extended recovery, normal newborn and normal vaginal delivery cases. Pathology 1. A pathology report must be completed within 10 days after the biopsy or surgery is performed. 2. Guidelines for pathology report a. Patients name and patients individual identifiers, such as date of birth, patient ID number, or Social Security number b. A case number, which is used to identify the specimen c. The date and type of the procedure by which the specimen was obtained (for instance, a blood sample, surgery, or biopsy) d. The patients medical history and current clinical diagnosis e. A general description of the specimen received in the laboratory f. A detailed description of what the pathologist sees during microscopic examination of the specimen g. The final diagnosis, which is the "bottom line" of the testing process. h. The name and signature of the pathologist, as well as the name and address of the pathology laboratory i.
Clinical Entries:
1. All clinical entries in the patient’s medical record shall be accurately dated, timed and authenticated.
2. All verbal orders for treatment shall be authenticated by the responsible practitioner within 24 hours.
3. Physician assistants and nurse practitioner may enter orders including admission orders. Orders do not require counter-authentication by the physician.
4. Progress notes should be documented or dictated with a frequency that reflects appropriate attending involvement but at least every day. Exceptions may be given to an obstetrical patient that has a discharge order entered from the day before. Progress notes should describe not only the patient’s condition, but also include response to therapy.
i. Admitting Note- The responsible provider must see the patient and document an admitting note (that justifies admission and determines the plan of treatment) within 24 hours of admission.
5. A minimum must include the patient’s condition, but also include the response to therapy in the progress notes.

Death/Transfer Summaries

1. Documentation of Death - A death summary is required for all deaths regardless of length of stay and must be documented at the time of death but no later than 7 days thereafter by the responsible practitioner.

Emergency Department Reports:

1. An ER Record is required for all visits.
2. It is expected to be completed within 24 hours of discharge/disposition from the Emergency Department.
3. Guidelines for Emergency Department Reports
i. Time and means of arrival ii. Pertinent history of the illness or injury, including place of occurrence and physical findings including the patient’s vital signs and emergency care given to the patient prior to arrival, and those conditions present on admission iii. Clinical observations, including results of treatment iv. Diagnostic impressions
v. Condition of the patient on discharge or transfer vi. Whether the patient left against medical advice vii. The conclusions at the termination of treatment, including final disposition, condition, and instructions for follow-up care, treatment and services

Medical Record Deficiencies

1. When it is discovered that certain entries, related to actions that were actually performed at the time of service but not properly documented, need to be amended, corrected, or entered after rendering the service, these entries must:
a. Be clearly and permanently identified as an amendment, correction or delayed entry, and
b. Be completed as soon as possible after the need for amendment, correction or delayed entry is identified, and
c. Clearly indicate the date, time, and author, and
d. Not delete but instead clearly identify all original content, and Identify or refer to the date and incident (original content) for which the delayed entry, amendment or correction is written, and
e. Identify any sources of information to support the delayed entry, amendment or correction.

There is no time limit to write a late entry, amendment or correction; however, the more time that passes, the less reliable the entry becomes.