Ideas That Work: No Need to Rewrite Unchanged H&Ps

REDUCE REDUNDANCY Don't rewrite outdated H&Ps if nothing has changed, just get the physician's verification and signature.

No Need to Rewrite Unchanged H&Ps

CMS and other authorities require history and physical forms to be completed within 30 days before surgery. At most facilities and for most cases, that's not a problem. But a busy orthopedic surgery schedule sometimes means patients have to wait a few weeks between their pre-op office visit and their procedure. And some states, ours for one, require H&P completion within 7 days of surgery. That double bind can put you under the gun with regard to H&P compliance. However, here's a solution — approved by the AAAHC surveyors who have seen it in action at our facility — ?that will keep your staff from having to needlessly re-write the entire H&P on the day of surgery.

If the patient's condition hasn't changed since the assessment, the surgeon can write "No changes" on the front of the H&P, along with the current date and his signature to bring the form into compliance. One of our surgeons even ordered his own "No changes from previous H&P" rubber stamp to save a few seconds. And the H&P form programmed into our EMR system includes a "No changes" checkbox with a space for initials and the date.

Susan Stanfield, RN, BS
Institute of Orthopaedic Surgery
Las Vegas, Nev.
[email protected]