AS I SEE IT
Ins and Outs of H&P Make sure you know the how, what and when behind these critical assessments BY DEBRA STINCHCOMB AND REGINA BOORE
The minimum re quire ment for a preop his tory and
physical Debra Stinchcomb
Regina Boore
(H&P) is well defined in the Centers for Me -
di care & Medicaid Services’ (CMS) Con ditions for Coverage (CfC). 1. According to §416.52 Condi- tions for Coverage Q-0261 (Rev. 71, Issued: 05-13-11, Effective: 5-13-11-Implementation: 05-13- 11) §416.52(a) Standard: Admis- sion and Pre-surgical Assessment: Not more than 30 days before the date of the scheduled surgery, each patient must have a comprehen- sive medical history and physical assessment completed by a physi- cian (as defined in section 1861(r) of the Act) or other qualified prac- titioner in accordance with appli- cable State health and safety laws, standards of practice, and ASC policy. (Please check your state and accrediting body requirements to ensure you will not be held to a more stringent timeframe)
2. Interpretive Guidelines §416.52(a) (1) The purpose of a comprehen- sive medical history and physical assessment (H&P) is to determine whether there is anything in the pa- tient’s overall condition that would affect the planned surgery, such as a medication allergy, or a new or existing co-morbid condition that requires additional interventions to reduce risk to the patient, or which may even indicate that an ASC set- ting might not be the appropriate setting for the patient’s surgery. The H&P must be comprehensive in order to allow assessment of the
patient’s readiness for surgery and is required regardless of the type of surgical procedure. The H&P should specifically indicate that the patient is cleared for surgery in an ambulatory setting.
Who Should Do an H&P A physician or other qualified licensed practitioner, such as a physician’s assis- tant (PA) or a nurse practitioner, may complete and document a patient’s medical history and physical examina- tion, if their scope of practice allows it in their state. RNs cannot do medical history and physical assessments; they are trained to do a nursing assessment. More than one qualified practitio- ner can participate in performing, doc- umenting and authenticating an H&P for a single patient. When performance, documentation and authentication are split among qualified practitioners, the practitioner who authenticates the H&P will be held responsible for its contents. In ASCs, the H&P may be com-
pleted by the patient’s primary care practitioner, rather than a member of the ASC’s medical staff. The ASC’s policy on H&Ps should address sub- mission of an H&P prior to the patient’s scheduled surgery date by a physician who is not a member of the ASC’s medical staff and should indi- cate whether it will accept H&Ps per- formed by a qualified licensed individ- ual who does not practice at the ASC but is acting within his/her scope of practice under state law or regulations.
What Is a Comprehensive H&P, When Should It Be Done As stated above, the §416.52(a) Stan- dard:
Admission and Assessment requires the H&P to be 10 ASC FOCUS OCTOBER 2017 |
www.ascfocus.org
completed and documented for each ASC patient no more than 30 calen- dar days prior to the date the patient is scheduled for surgery in the ASC. In cases where the patient is sched- uled for two surgeries
in
the ASC
within a short period of time, the same H&P may be used so long as it is com- pleted no more than 30 calendar days before each surgery. For example, if a patient has two surgeries for cataracts scheduled, one eye on May 3, and the other eye on May 18, an H&P per- formed on April 20th could be used for both surgeries.
Pre-surgical
The H&P is still required in those cases where the patient is referred to the ASC for surgery on the same day as the referral and the referring physician has indicated it is medically necessary for the patient to have the surgery on the same date. The H&P may be per- formed by the referring physician, if the ASC’s policies permit this, or qual- ified personnel in the ASC. If there are elements of the H&P that are essential to the performance of the physician assessment required under §416.42(a) or under this requirement at §416.52(a) (1), based on the type of procedure to be performed as well as applicable state health and safety laws, standards of practice, or ASC policy, and those elements cannot be completed prior to the scheduled time of the surgical pro- cedure, then it is questionable whether the case is suitable for that ASC. The H&P may be performed on the same day as the surgical procedure, and may be performed in the ASC, as long as it is conducted by qualified personnel, it is comprehensive, and the results of the H&P are placed in the patient’s medi- cal record prior to the surgical procedure (see §416.52(a)(3). It is not acceptable
The advice and opinions expressed in this article are those of the authors and do not represent official Ambulatory Surgery Center Association policy or opinion.
Page 1 |
Page 2 |
Page 3 |
Page 4 |
Page 5 |
Page 6 |
Page 7 |
Page 8 |
Page 9 |
Page 10 |
Page 11 |
Page 12 |
Page 13 |
Page 14 |
Page 15 |
Page 16 |
Page 17 |
Page 18 |
Page 19 |
Page 20 |
Page 21 |
Page 22 |
Page 23 |
Page 24 |
Page 25 |
Page 26 |
Page 27 |
Page 28 |
Page 29 |
Page 30 |
Page 31 |
Page 32 |
Page 33 |
Page 34 |
Page 35 |
Page 36 |
Page 37 |
Page 38 |
Page 39 |
Page 40
