CMS SOM App. A, Tag A-0358

§482.22(c)(5) Include a requirement that --

(i) A medical history and physical examination be completed and documented for

each patient no more than 30 days before or 24 hours after admission or registration, but

prior to surgery or a procedure requiring anesthesia services, and except as provided

under paragraph (c)(5)(iii) of this section. The medical history and physical examination

must be completed and documented by a physician (as defined in section 1861(r) of the

Act), an oral and maxillofacial surgeon, or other qualified licensed individual in accordance

with State law and hospital policy

Interpretive Guidelines §482.22(c)(5)(i)

The purpose of a medical history and physical examination (H&P) is to determine whether there

is anything in the patient's overall condition that would affect the planned course of the patient's

treatment, such as a medication allergy, or a new or existing co-morbid condition that requires

additional interventions to reduce risk to the patient.

The Medical Staff bylaws must include a requirement that an H&P be completed and

documented for each patient no more than 30 days prior to or 24 hours after hospital admission

or registration, but prior to surgery or a procedure requiring anesthesia services except when the

patient is receiving an outpatient surgical or procedural services and when the medical staff has

developed and maintained a policy (in accordance with §482.22(c)(5)(v)) that identifies specific

patients that do not require a comprehensive medical H&P, or any update to it, prior to the

specific outpatient surgery or procedure.

The H&P may be handwritten or transcribed, but always must be placed within the patient’s

medical record within 24 hours of admission or registration, or prior to surgery or a procedure

requiring anesthesia services, whichever comes first.

An H&P is required prior to surgery and prior to procedures requiring anesthesia services,

regardless of whether care is being provided on an inpatient or outpatient basis. (71 FR 68676)

An H&P that is completed within 24 hours of the patient’s admission or registration, but after the

surgical procedure, procedure requiring anesthesia, or other procedure requiring an H&P would

not be in compliance with this requirement.

The medical history and physical examination must be completed and documented by a

physician (as defined in section 1861(r) of the Act), oral and maxillofacial surgeon, or other

qualified licensed individual in accordance with State law and hospital policy.

Section 1861(r) defines a physician as a:

• Doctor of medicine or osteopathy;

• Doctor of dental surgery or of dental medicine;

• Doctor of podiatric medicine;

• Doctor of optometry; or a

• Chiropractor.

In all cases the practitioners included in the definition of a physician must be legally authorized

to practice within the State where the hospital is located and providing services within their

authorized scope of practice. In addition, in certain instances the Social Security Act attaches

further limitations as to the type of hospital services for which a practitioner is considered to be a

“physician.” For example, a chiropractor is considered a physician only with respect to

treatment by means of manual manipulation of the spine (to correct a subluxation).

Other qualified licensed individuals are those licensed practitioners who are authorized in

accordance with their State scope of practice laws or regulations to perform an H&P and who are

also formally authorized by the hospital to conduct an H&P. Other qualified licensed

practitioners could include nurse practitioners and physician assistants.

More than one qualified practitioner can participate in performing, documenting, and

authenticating an H&P for a single patient. When performance, documentation, and

authentication are split among qualified practitioners, the practitioner who authenticates the H&P

will be held responsible for its contents. (71 FR 68675)

A hospital may adopt a policy allowing submission of an H&P prior to the patient’s hospital

admission or registration by a physician who may not be a member of the hospital's medical staff

or who does not have admitting privileges at that hospital, or by a qualified licensed individual

who does not practice at that hospital but is acting within his/her scope of practice under State

law or regulations. Generally, this occurs where the H&P is completed in advance by the

patient’s primary care practitioner. (71 FR 68675)

When the H&P is conducted within 30 days before admission or registration, an update must be

completed and documented by a licensed practitioner who is credentialed and privileged by the

hospital’s medical staff to perform an H&P. (71 FR 68675) (See discussion of H&P update

requirements at 42 CFR 482.22(c)(5)(ii).)

Surveyors should cite noncompliance with the requirements of 42 CFR

482.22(c)(5) for failure by the hospital to comply with any of this standard's components.

Survey Procedures §482.22(c)(5)(i)

• Review the medical staff bylaws to determine whether they require that a physical

examination and medical history be done for each patient no more than 30 days before or 24

hours after admission or registration by a physician (as defined in section 1861(r) of the Act),

an oral and maxillofacial surgeon, or other qualified licensed individual in accordance with

State law and hospital policy. Verify whether the bylaws require the H&P be completed

prior to surgery or a procedure requiring anesthesia services.

• Review the hospital’s policy, if any, to determine whether other qualified licensed

individuals are permitted to conduct H&Ps to ensure that it is consistent with the State’s

scope of practice law or regulations.

• Verify that non-physicians who perform H&Ps within the hospital are qualified and have

been credentialed and privileged in accordance with the hospital’s policy.

• Review a sample of inpatient and outpatient medical records that include a variety of patient

populations undergoing both surgical and non-surgical procedures to verify that:

o There is an H&P that was completed no more than 30 days before or 24 hours after

admission or registration, but, in all cases, prior to surgery or a procedure requiring

anesthesia services, except when an assessment is completed and documented

pursuant to §482.22(c)(5)(iii); and

o The H&P was performed by a physician, an oral and maxillofacial surgeon, or other

qualified licensed individual authorized in accordance with State law and hospital

policy.