CMS SOM App. A, Tag A-0458

(i) Evidence of--

(A) A medical history and physical examination completed and documented

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)(4)(i)(C) of this section. The

medical history and physical examination must be placed in the patient’s

medical record within 24 hours after admission or registration, but prior

to surgery or a procedure requiring anesthesia services.

Interpretive Guidelines §482.24(c)(4)(i)(A)

Except for those patients who are specified as not requiring a comprehensive history and physical for

specific outpatient surgeries and procedures under §482.22(c)(4)(i)(C) (see 71 FR 68676), the

medical record must include documentation that a medical history and physical examination

(H&P) was completed and documented for each patient no more than 30 days prior to hospital

admission or registration, or 24 hours after hospital admission or registration, but prior to surgery

or a procedure requiring anesthesia services.

The purpose of an 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 an allergy to a

medication that must be avoided, or a co-morbidity that requires certain additional interventions

to reduce risk to the patient.

The H&P documentation must be placed in the medical record within 24 hours of admission or

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

inpatient, outpatient, or same-day surgeries or procedures. The H&P may be handwritten or

transcribed. For those patients that require an H&P, an H&P that is completed within 24 hours

of the patient’s admission or registration, but after surgery or a procedure requiring anesthesia,

would not be in compliance.

Survey Procedures §482.24(c)(4)(i)(A)

• Review a sample of inpatient medical records for various types of patients and outpatient

medical records for patients having same day surgery or a procedure requiring anesthesia,

except for those patients who are specified as not requiring a comprehensive history and

physical for specific outpatient surgeries and procedures to determine whether:

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

admission or registration, but, for all cases involving surgery or a procedure

requiring anesthesia services, prior to the surgery or procedure, except for those

patients who are specified as not requiring a comprehensive history and physical for

specific outpatient surgeries and procedures;

o The H&P documentation was placed in the medical record within 24 hours after

admission or registration, but, for all cases involving surgery or a procedure

requiring anesthesia services, prior to the surgery or procedure, except for those

patients who are specified as not requiring a comprehensive history and physical for

specific outpatient surgeries and procedures;