Patient History & Physicals

[Chilly_hands]

Recently the hospital that I work for implemented the surgeons to do H&P's on patients within 30 days of scheduled surgery and then to update the H&P the day of surgery. (Sounds reasonable to me, of course).

It's been a little rough to get the surgeons to comply, most H&P's are done well over a month before scheduled surgery. That's not acceptable and then the physician is given a blank form to fill out the day of surgery.

One excellent surgeon recently updated his H&P from 3 months prior, with just initials and no change. That isn't acceptable according to the policy. The nursing staff have been instructed to not let any patient go to surgery without the proper H&P on the chart. I happen to be the patients admission nurse and followed all the processes implemented. The OR nurse came to do her part and I informed her that the doc didn't complete the H&P. She said she would take care of that and walked to the chart, opened the H&P and filled it in completely from the information in the chart. Never once was a stethoscope placed on that patient other than my assessment.

My question: Is any other OR having problems with H&P's and is this ethical that a nurse would do this to a form already signed by a surgeon? When I brought this information to my boss, I was told to "let it go, don't get him mad today".

[kiwi77]

Yes, everywhere I work this has been an issue. I have not seen it be OK for anyone but a PA, resident, CRNA or anesthesiologist update the H&P. None of the OR nurses have taken upon themselves to update the H&P because our policy doesn't allow that. But guess who is written up first by risk management if the chart is audited and it is seen that the H&P wasn't updated the date of surgery?

I've had surgeons tell me to not hold up the case, take the patient on to the OR, that they will update the H&P when they dictate after the surgery. Guess what? They forget and it doesn't get done.

[OPCC]

Our H&Ps and any pre-op labs are completed within the week prior to scheduled procedure by the patients local physician and then placed on the chart ready for our outreach surgeon who comes 1-2 times a month for scheduled procedures. Then I still have a hard time getting him to sign off the documents that have already been done for him. All they want to do is do the procedure. It makes me feel a little better to know that there are others out there with the same problems. I thought we were the only ones that were "failures".

[TallBlondie]

We have this new rule as well and change can be difficult at first but time and habit can make it happen. One thing I do for the most non-compliant docs is to run the chart over to wherever the surgeon is (surgeon's lounge, pacu with his last patient and get him to scribble in -No changes. [date] signature- Or I will put a brightly colored post-it on the page where they are to sign sticking out of the chart with a note saying 'sign me!' This rule shouldn't come back on the circs, I beleive it is there to cover the surgeons. Also, while an RN cannot sign off on the update, maybe hospital policy allows for them to fill in an H&P short form and have the surgeon just sign off on it.:studyowl: