History and Physicals

[TCherie]

I was given the task to find a better way to get history's and physical's on a chart before the patient goes to surgery. (I work in same day). It has been an age old problem for Drs to dictate their H & P's but maybe you can give me some ideas how you do it in your hospital. We have trouble from Medical Records on up the chain.... Our policy is no surgery if H & P isn't done within 24 hrs of surgery. Ha Ha... they don't enforce that either... Thanks for suggestions. TCherie

[June55Baby]

I was given the task to find a better way to get history's and physical's on a chart before the patient goes to surgery. (I work in same day). It has been an age old problem for Drs to dictate their H & P's but maybe you can give me some ideas how you do it in your hospital. We have trouble from Medical Records on up the chain.... Our policy is no surgery if H & P isn't done within 24 hrs of surgery. Ha Ha... they don't enforce that either... Thanks for suggestions. TCherie

Age old problem TCherie... If you find a solution, I want to know too ! ! !

So far we have tried the following and had improvement but still not 100%:

1. Pre-Printed forms with all required elements of H&P listed

2. A nurse assigned as H&P Nazi who refuses to allow a patient into the OR Suite without an H&P

3. Massive education to physicians

And still every week somebody "slips through" without an H&P or without an updated H&P.

I will be monitoring this thread to see if anybody has suggestions. In the meantime, good luck!

[plumrn, BSN, RN]

Problem at our hospital, too. I've been a nurse for many years, and it has always been a problem. The hospitals will just have to put their foot down, and tell the doctors, Your case is cancelled, You tell the patient. Next!

[Annita Frazier]

We are lucky to see an H&P before discharge:crying2: . No suggestions here.

[lifeisbeautiful]

The hospitals will just have to put their foot down, and tell the doctors, Your case is cancelled, You tell the patient. Next!

There's the answer. Plain and simple. The doctor's stomp their feet and throw a fit when their case is delayed due to paperwork problems, but the MD is the cause of this! If the doctor would have taken the time to make sure their patients H&P was filled out or updated prior to surgery, there wouldn't be this problem.

[sharann, BSN, RN]

There's the answer. Plain and simple. The doctor's stomp their feet and throw a fit when their case is delayed due to paperwork problems, but the MD is the cause of this! If the doctor would have taken the time to make sure their patients H&P was filled out or updated prior to surgery, there wouldn't be this problem.

Exactly.