We recently had our unannounced Joint Commission survey. A standard that we were not in compliance on was PC.01.02.03 that states " For a medical history and physical examination that was completed within 30 days prior to registration or inpatient admission, an update documenting any change in patient condition is completed within 24 hours after registration or inpatient admission, but prior to surgery or a procedure requiring anesthesia services."
In order to correct this, we developed a sticker to be placed on the chart that states that the H&P has been reviewed and no changes are noted. If there are changes, then there is place for those.
We place those on there and the surgeons are to fill them out and sign them prior to surgery since the attending that dictated the H&P are not there in time to sign them.
We are getting a lot of resistance from the surgeons because they feel that they are making an addendum to someones elses H&P and that makes them liable for any unknown or unforeseen conditions that may have developed since the H&P.
I would like to know how everyone else is meeting this standard.
Thank you.
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We recently had our unannounced Joint Commission survey. A standard that we were not in compliance on was PC.01.02.03 that states " For a medical history and physical examination that was completed within 30 days prior to registration or inpatient admission, an update documenting any change in patient condition is completed within 24 hours after registration or inpatient admission, but prior to surgery or a procedure requiring anesthesia services."
In order to correct this, we developed a sticker to be placed on the chart that states that the H&P has been reviewed and no changes are noted. If there are changes, then there is place for those.
We place those on there and the surgeons are to fill them out and sign them prior to surgery since the attending that dictated the H&P are not there in time to sign them.
We are getting a lot of resistance from the surgeons because they feel that they are making an addendum to someones elses H&P and that makes them liable for any unknown or unforeseen conditions that may have developed since the H&P.
I would like to know how everyone else is meeting this standard.
Thank you.