Memo

To:Surgeons, Physician Assistants, Fellows and Residents
From: Dr. David Dries, Assistant Medical Director, Regions Hospital

Dana Langness, Senior Director of Surgical Services
Dr. Matthew Layman, Director of Perioperative Services


Date: October 11, 2010


Topic: History and Physical Documentation & the Importance of Communicating Accurate Expectations
History and Physical Documentation

The Centers for Medicare and Medicaid Services (CMS) and The Joint Commission (TJC) require that a physician must complete a medical history and physical examination no more than 30 days before admission for elective surgery. Even though the medical history and physical may have been completed within 30 days before admission, due to changes in current regulatory guidelines, an update to the patient’s condition since the assessment (H & P) must be recorded at the time of admission.

CMS and TJC require each patient to be reassessed on the day of surgery, inpatient or outpatient, prior to surgery. The anesthesiologist will reassess each patient for any changes in the patient’s condition for those patients with an H & P completed within 30 days before the patient was admitted. This reassessment will serve as the update to the medical history and physical and will be documented in the patient’s medical record.
However, when the patient has a medical history and physical examination that was completed more than 30 days before the admission for surgery or is not signed and dated by the provider, the surgeon will need to do a new, complete medical history and physical before the patient can have surgery.

Note: Except in emergencies, a dictated medical history and physical examination that has not yet been transcribed and attached to the medical record, will not meet regulatory standards. In an emergency, when there is no time to record the complete history and physical examination, a progress or admission note describing a brief history and appropriate physical findings and the preoperative diagnosis must be recorded in the medical record before surgery.

We can no longer accept the practice of performing the medical history and physical examination the morning of surgery. Unless there are unusual extenuating circumstances (e.g. patient traveling great distances), the patient’s medical history and physical examination may only be done the morning of surgery in emergency situations.
Surgery will be delayed until the issue with the patient’s medical history and physical has been reconciled unless the surgery to be performed is due to an emergency.

The Importance of Communicating Accurate Expectations

It is important that we communicate accurate expectations to family members regarding a patient’s stay in PACU.
We continue to have families experience frustration due to several issues:
1. They were told by the surgeon an estimated PACU timeframe that was too short;
2. They were told the patient had been moved to PACU when they were really still in the OR;
3. Lengthy close times are not being considered when communicating wait times to families (e.g. the surgeon tells the family that the surgery is over and the patient will be in PACU for about one hour when in actuality they are still closing and, in some instances, the closing is lengthy)

Therefore, we ask that when communicating PACU times, you use our average of 60-90 minutes from entry into PACU. Also, when you give a time estimate, please take into consideration the time the patient will remain in the OR for closing before moving to PACU.

We appreciate your help with setting clear expectations for our families.

cc: Gretchen Leiterman
Ken Holmen, MD