As a concurrent record reviewer for an acute care facility, you have asked Dr. Crossman to

Question

provide an updated history and physical for one of her recent admissions. Dr. Crossman pages
through the medical record to a copy of an H&P performed in her office a week before admission.
You tell Dr. Crossman
A. a new H&P is required for every inpatient admission.
B. that you apologize for not noticing the H&P she provided.
C. the H&P copy is acceptable as long as she documents any interval changes.
D. Joint Commission standards do not allow copies of any kind in the original record.

Answer 1

C Joint Commission and COP allow a legible copy of a recent H&P done in a doctor's office in lieu
of an admission H&P as long as interval changes are documented in the record upon admission.
In addition, when the patient is readmitted within 30 days for the same or a related problem, an
interval history and physical exam may be completed if the original H&P is readily available.