H&P Audit a Success at 96.1%
H&Ps obtained within 30 days prior to admission must have an Update within 24 hours of inpatient admission, but always prior to a surgery or procedure requiring sedation or Anesthesia services.
Last fall, prior to our Joint Commission survey, CMS (aka Medicare) became more prescriptive as to what the Update must include in its documentation. Specifically the Update documentation must indicate:
1. The H&P was reviewed; and
2. The patient was examined for any changes that might be significant to the planned course of treatment; and
3. Any pertinent changes or the absence of changes
At the time of survey in many cases our current documentation stated #3 but only inferred #1 and #2. Following rigorous discussion with our very reasonable physician surveyor, it was clear that we must comply with CMS' specificity. Cath Lab and Pain Clinic were already largely in compliance; however for Surgery, where the Anesthesia Record was relied upon as evidence of the H&P Update, change was necessary.
While Anesthesiologists regularly assess patients, their assessment is specific to the provision of anesthesia -- specifically heart, lungs, and airway. They are not assessing the patient for changes specific to the surgical site. In many instances it may be inappropriate to expect an Anesthesiologist to evaluate all changes that could impact the patient's fitness for the specific procedure being performed or the impact of any changes on the planned course of treatment developed by the surgeon. Surgeons and Interventionalists are already doing this assessment, but just not documenting it.
We created a quick way for Surgeons and Interventionalists to document the H&P Update:
I have reviewed the History and Physical and examined the patient.
(Check one of the following)
___ There are no changes that are relevant to the planned course of treatment; OR
___ There have been interval changes* as listed below:
This was implemented in late January 2012 and audited per the Joint Commission prescribed four (4) months, which concluded at the end of May. We have successfully passed our audit having averaged over a 90% completion rate (96.1%).
H&P Updates have been a confusing subject in all hospitals. The good news: We are not nearly as confused as other hospitals, in part thanks to the benevolence and clarity of our physician surveyor. Many other hospitals were so confused about what had to be in the Update, they were requiring physicians to simply complete a new H&P if the current one was over 24 hours old!
The bad news: While all seem to be in consensus that concept is a good one, following the documentation requirement is inefficient for those who swing rooms in particular.
The most common confusion we hear is "who has to do this update?" and "Isn't this Anesthesia's responsibility?" The answer to the latter is "No". Anesthesia clears the patient for general anesthesia, not for the specific procedure being performed.
CMS (aka Medicare) is looking for a responsible provider to attest that nothing in the patient's condition has changed that would warrant not performing the planned procedure (eg: knee replacement planned, but on the morning of surgery the knee is red and swollen). The specific language in the regulation is "The patient was examined for any changes that might be significant to the planned course of treatment". The extent of the examination is up to the individual physician, and of course can take into account the assessment that Anesthesia has performed for their role in the care.
So, our current stance is: If you can prescribe the procedure (including dentists and podiatrists), you can consider whether or not the patient still needs the procedure on the day of surgery and document the Update.
Lastly we received one request to have our legal counsel review the language in Update documentation to ensure it does not create any additional legal liability. As CMS essentially creates a national standard by their regulation and we are following it, it does not create legal liability.