CMS SOM App. A, Tag A-0359

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

(ii) An updated examination of the patient, including any changes in the patient's

condition, be completed and documented within 24 hours after admission or

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

when the medical history and physical examination are completed within 30

days before admission or registration, and except as provided under paragraph

(c)(5)(iii) of this section. The updated examination of the patient, including any

changes in the patient's condition, 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)(ii)

The Medical Staff bylaws must include a requirement that when a medical history and physical

examination has been completed within 30 days before admission or registration, an updated

medical record entry must be completed and documented in the patient's medical record within

24 hours after admission or registration, 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 outpatient surgery or procedure.

The examination must be conducted by a licensed practitioner who is credentialed and privileged

by the hospital’s medical staff to perform an H&P. In all cases, the update must take place prior

to surgery or a procedure requiring anesthesia services. The update note must document an

examination for any changes in the patient's condition since the patient's H&P was performed

that might be significant for the planned course of treatment. The physician or qualified licensed

individual uses his/her clinical judgment, based upon his/her assessment of the patient’s

condition and co-morbidities, if any, in relation to the patient’s planned course of treatment to

decide the extent of the update assessment needed as well as the information to be included in

the update note in the patient’s medical record.

If, upon examination, the licensed practitioner finds no change in the patient's condition since the

H&P was completed, he/she may indicate in the patient's medical record that the H&P was

reviewed, the patient was examined, and that "no change" has occurred in the patient's condition

since the H&P was completed (71 FR 68676). Any changes in the patient’s condition must be

documented by the practitioner in the update note and placed in the patient’s medical record

within 24 hours of admission or registration, but prior to surgery or a procedure requirement

anesthesia services. Additionally, if the practitioner finds that the H&P done before admission is

incomplete, inaccurate, or otherwise unacceptable, the practitioner reviewing the H&P,

examining the patient, and completing the update may disregard the existing H&P, and conduct

and document in the medical record a new H&P within 24 hours after admission or registration,

but prior to surgery or a procedure requiring anesthesia.

Survey Procedures §482.22(c)(5)(ii)

• Review the medical staff bylaws to determine whether they include provisions requiring

that, when the medical history and physical examination was completed within 30 days

before admission or registration, an updated medical record entry documenting an

examination for changes in the patient's condition was completed and documented in the

patient's medical record within 24 hours after admission or registration.

• Determine whether the bylaws require that, in all cases involving surgery or a procedure

requiring anesthesia services, the update to the H&P must be completed and documented

prior to the surgery or procedure.

• In the sample of medical records selected for review, look for cases where the medical

history and physical examination was completed within 30 days before admission or

registration. Verify that an updated medical record entry documenting an examination

for any changes in the patient's condition was completed and documented in the patient's

medical record within 24 hours after admission or registration. Verify that in all cases

involving surgery or a procedure requiring anesthesia services, the update was completed

and documented prior to the surgery or procedure.