History and Physicals: Understanding the CMS and Joint Commission Standards for Hospitals

Laura A. Dixon

Laura A. Dixon

Laura A. Dixon served as the Director, Facility Patient Safety and Risk Management, and Operations for COPIC from 2014 to 2020. In her role, Ms. Dixon provided patient safety and risk management consulting and training to facilities, practitioners and staff in multiple states. Such services included the creation of and presentations on risk...
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Laura A. Dixon

CMS made a change effective November 29, 2019, regarding History and Physicals. Healthy outpatients may not be required to have a history and physical. Many hospitals are confused over what is required by hospitals in the CMS hospital Conditions of Participation Manual and by the Joint Commission standards. In fact, CMS noted in a past memo, that they frequently receive questions on this, and in response, CMS issues a clarification statement. The process to do will be explained including a required policy, Medical Staff and Board approval, revised medical staff bylaws, and more. This webinar by industry expert Laura A. Dixon, BS, JD, RN will discuss what should be in the policy.

After attending this webinar, you can learn what is required to be in the history and physicals and how to meet compliance with both the CMS hospital conditions of participation and with the Joint Commission standards. CMS has five separate tag numbers. CMS has also issued a deficiency memo so information will be given on how many hospitals received deficiencies in this area. This will also include the standards for critical access hospitals.

The Joint Commission has many frequently asked questions on H&Ps that will be discussed including delegation of H&P, H&P for outpatient procedures, medical students doing H&Ps, podiatrist or dentist doing H&P, prenatal assessment, update requirements content of the H&P, and authentication of H&Ps. Hospitals need to ensure that hospital policies and procedure meet the H&P requirements. Medical staff by-laws must also comply with the regulations and interpretive guidelines and standards.

Webinar Objectives

  • Recall that CMS has five H&P requirements in the hospital conditions of participation that all hospitals that accept Medicare must follow
  • Identify Joint Commission standards on H&P
  • Recall that CMS issued clarification changes for hospitals on H&Ps in a CMS survey and certification memo
  • Describe that the hospital must have medical staff by-laws and policies that include the requirements for H&Ps
  • Discuss what hospitals must do to implement the new rule that H&Ps do not need to be done on healthy outpatients

Webinar Agenda

  • Introduction to the CMS hospital CoP requirements
    • CMS current hospital CoP manual
    • How to locate changes
    • Tag 358 and 359 on H&P in the Medical Staff section
    • Tag 461 and 463 on H&P in the Medical Records section
    • Tag 952 in surgery services
    • The new exception for healthy outpatients
    • How to draft a policy for the new exception
    • How to process the issue and MS and Board approval
    • Medical staff by-laws
    • 24-hour update rule and the 30-day rule
    • Updates the day of surgery or procedure requiring anesthesia
    • What constitutes anesthesia
    • H&P on the chart before surgery
    • Exceptions for emergencies
    • Who can perform an H&P
    • When an H&P is required
    • Documentation in the medical record
    • H&P done by a non-credentialed practitioner
    • CMS clarification memo
    • CAH requirements and new tag numbers in 2020
  • The Joint Commission H&P standards
    • Medical staff chapter
    • Record of care chapter standards
    • Provision of care chapter standards
    • Documenting H&P
    • 24 hour and the 30-day rule
    • MS by-laws
    • Qualified physician and delegation
    • FAQ on H&P
    • H&P for outpatient procedures
    • Medical students doing H&P
    • Content of H&P
    • Podiatrist doing H&P
    • Prenatal record
    • Authentication of the H&P
    • H&P for outpatient procedures

Who Should Attend

  • Chief Medical Officer
  • Chief Nursing Officer
  • OR staff and OR nurses
  • Director of HIM
  • PAT department staff
  • Outpatient nurses and staff
  • Surgery nurses
  • Chief Risk Officer
  • Chief Operating Officer
  • MS staff and physicians, PAs and NPs
  • Risk Managers
  • Compliance Officers
  • Director of Regulatory Affairs
  • Outpatient Director
  • Hospital legal counsel
  • Joint Commission Director
  • Director of Health Information Management
  • Anyone involved in ensuring compliance with the history and physical requirements from the Joint Commission and CMS hospital conditions of participation
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