No Time to Read: The Importance of the History and Physical

What is the point of an H&P and should I be doing more than just making sure it’s in the list of notes?

Q: 

Dear Masked Maven,

I know that you are supposed to check that a history and physical (H&P) is done before bringing a patient to the OR. But do I have to actually read it? We are so busy, and things move so fast that I am usually getting pushed out the door to go get a patient once we see that the document is in the computer. In fact, sometimes they send me to get the patient before it’s in the chart and they tell me they’ll “stop me” if it doesn’t drop in time. What is the point of an H&P and should I be doing more than just making sure it’s in the list of notes?

Sincerely,

No Time to Read

A:

Dear No Time to Read,

Wouldn’t it be wonderful if your surgeon would come to you prior to every procedure and give you a lengthy, comprehensive report on each patient, including their presenting symptoms, progression through the health care system, and complicating comorbidities? What if I told you they already have? This is the H&P. While your surgeon likely doesn’t have time for a lengthy face-to-face dialogue to convey all the patient’s details, they do make time to complete an H&P. They do this not only because it is legally required but also because it is a great tool for communicating each patient’s story to the team.

Benefits

It is important to read the full H&P (not just the updated H&P). The original surgeon consult with an assessment, diagnosis, and plan will have bits of information and helpful clues not only about the patient’s condition but also about possible nuances to the case. Reading the electronic medical record for this information may seem like a time burner; however, it will make you more efficient because you’ll be prepared for those small deviations to planned procedures.

Reading the H&P can also help you avoid possible near misses. The record will occasionally mention concerns that aren’t addressed on the consent. You can ask clarifying questions before the patient is anesthetized and clarify and address any issues with a simple conversation rather than running into confusion while the patient is unconscious. You can also make sure that the supplies, instruments, and equipment for your procedure are correct. If someone prepared for a low anterior colon resection but the H&P indicates a transverse colon resection, you can catch the inconsistency before the patient comes in the room rather than running around like crazy to correct the problems after realizing you’re involved in a slightly different case than what was anticipated.

All in all, the H&P should not be viewed as a hurdle to jump to just get on with the day, but rather a valuable tool to help you provide better, more informed patient care as a circulator. You would never assume care of a patient without a hand-off report—think of the H&P in the same manner. It is a report to you so that you can assume care of that patient. You should follow your facility’s policy on completing and updating the H&P. Of note: the comprehensive H&P can often be completed by a primary care physician, but it needs to be dated no more than 30 days prior to the procedure.

Stand Firm or Adapt

You have two options when it comes to being rushed out of the room to get a patient prior to the H&P being completed: stand firm or adapt.

• Stand firm. It is reasonable (and right) to kindly decline getting the patient before the H&P is available in the electronic medical record and you have taken time to read it. This is especially true if what you need is a comprehensive H&P.
• If, however, you aren’t comfortable with setting that boundary then you can usually adapt and find a workstation in the preop area or in the patient’s room to check that the documentation is appropriate (and read it) prior to taking your patient to the OR. This is especially true if all you need is the H&P update. You may get a reputation for being a tad slow, but it is better than a reputation of not knowing what is going on.

Making sure that there is an H&P not only helps ensure better, safer care for your patient, it also protects you and your team. Saying you have no time to read is like saying you don’t have time for safety. There is always time for safety and there is always (with a few emergency-type exceptions) time to read.

Best,

The Masked Maven

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