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Keeping Your H&Ps Current: 8 Dos and Don'ts

Publish Date: 1/23/2013
Lots can happen in between the time when patients are scheduled for surgery and the day of their surgery. They may start on a new medication, suffer an injury or develop an illness. If a surgeon is unaware of a change in a patient's history, the consequences can be dire.

It is critical for hospitals and ASCs to ensure patients have a current history and physical (H&P) in their medical chart, says Lisa Spruce, RN, DNP, ACNS, ACNP, ANP, CNOR, director of evidence-based perioperative practice for AORN. CMS requires each patient to have a comprehensive medical history and physical assessment completed by a physician not more than 30 days before the date of the scheduled surgery. Meeting this requirement and obtaining a current H&P is a challenge many organizations face.

"It's definitely a problem I've seen quite a bit," Dr. Spruce says. "Part of the issue is that patients are often scheduled for surgery 2-3 months in advance. They may go in for their pre-op visit close to scheduling, get their H&P taken, have all of their paperwork compiled and sent to the facility and it's already going to be outdated because the surgery isn't scheduled for a few months after the H&P is performed. When the patient comes in for the surgery, an outdated H&P can easily be overlooked. I see this in every surgical setting."

Keeping an H&P current is not just important for patient safety. "When accreditors come in, that's often one of the first things they will look at," Dr. Spruce says.

An outdated H&P can also impact an organization's reimbursement, says Mary Sturm, RN, MBA, senior vice president of clinical operations for Surgical Management Professionals, a Sioux Falls, S.D.-based organization that specializes in management and consulting services for ASCs, physician offices and physician-owned hospitals.

"There are constant reimbursement reviews and scrutiny that organizations are all undergoing," Sturm says. "We know that both the MAC and RAC auditors are using lack of quality or current H&Ps as a means to interfere with reimbursement. They can do that because the regulations are very clear. It's a condition of being a Medicare provider that you have to have a current, legible, quality H&P on the chart."

Dr. Spruce and Sturm, identify eight dos and don'ts to keep H&Ps current.

1. Do review the H&P before surgery. A simple step perioperative professionals should take is to review the H&P prior to bringing patients back to the OR. "Look at the date on the H&P," Sturm says. "Then look for the attestation of the surgeon that they've updated the H&P on the day of surgery and that there are no changes or that the surgeon documents any changes in the patient's status. Make sure you see that attestation."

2. Do use tools to make updating an H&P easier for the surgeon. "One of the solutions hospitals and facilities use to help make sure surgeons review the H&P on the day of surgery is to include an addendum page with the H&P for the surgeon," Dr. Spruce says. "Then they just need to review the H&P with the patient, note on the addendum if there are any changes, sign and date it. We're not asking them to do a completely new one. They just have to review the H&P, to do their due diligence with your patients and make sure there haven't been any changes since the H&P was performed."

Another tool organizations can use is a stamp specially designed for H&P review, Sturm says. The stamp has two check boxes. One reads "The H&P has been reviewed and there are no changes in the patient's status." The other reads, "The H&P has been reviewed with the following changes" and there is a place for the surgeon to note changes. Then there is a signature and date line for the doctor. "This is stamped on the H&P usually on the operative day," she says."We require the surgeon to fill this out before the patient is taken back for surgery."

3. Do use a consistent process for updating H&Ps. Whether it's through use of an addendum page, stamp or some other mechanism for keeping H&Ps current, surgeons are more likely to perform required documentation tasks if the steps they need to follow at a facility are consistent, Sturm says. "When you start to vary processes, I think that's when the ball gets dropped. The more you create hardwired processes that you can educate the surgeons about, the more likely they are to do what they need to do. If surgeons know exactly what they need to do when they go to a certain hospital or surgery center in order for things to go smoothly, they will be more likely to follow the checklist so that the patient's surgery can proceed."

4. Do not bring patients back to the OR until the H&P is current. "I do not believe nurses should take their patients back to the OR unless the surgeon has reviewed the H&P," Dr. Spruce says. "I've seen patients put at risk because it wasn't done and something had occurred between the time they originally had their H&P and the day of their surgery. For nurses in particular, they should not feel pressured to take the patient back without those steps happening. Stand your ground, and go to your supervisor if necessary. Make sure you don't take a patient to the OR until that's completed."

5. Do not hesitate to redo an H&P. Sometimes it's worthwhile to do a new H&P on the day of surgery, Dr. Spruce says. "If there was a complication or something happened to the patient since the H&P was performed, just do another. I think you have to use your own judgment sometimes. If something significant happened to the patient and we need to make that very clear and detailed in the H&P, the best way to do that may be with a new H&P."

6. Do not rely on an H&P from another facility. "If a patient is coming in to a new facility, an H&P from another facility should not be updated," Dr. Spruce says. "The H&P should be redone."

7. Do a new H&P for repeat hospitalizations and readmissions. "Sometimes the patient may have had several hospitalizations, and they have an H&P from a previous visit in their medical record," Dr. Spruce says. "Even if it's been less than 30 days, don't think of that as a current H&P. It has to be redone."

The same should hold true for patients who are readmitted. "If a patient is getting readmitted, it's usually a complication or something else has happened," Dr. Spruce says. "In that case a new H&P should be performed and the old one should not be relied upon. I think that's safest for the patient."

8. Do remind difficult surgeons about implications of outdated H&Ps. Surgeons may forget about the importance of keeping H&Ps current, so it may be worthwhile to remind them of the many reasons why. "Information is power," Sturm says. "Appeal to their sense of reason and pocketbooks. Remind them that it's a quality and a fiscal issue."

Guidelines for Perioperative Practice


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