JCAHO Requirements on History & Physical Examination Records

The updated JCAHO standard for physical examination and history has a shorter time frame. You must include documentation that proves compliance in the patient's file prior to surgery or within 24 hours of admittance.

Documenting Current Status and Changes

• The updated history and physical examination must address the patient's current status and any changes in the patient's status. If no changes have occurred, record that in the patient's file.

Updated Physical Examination Form

• The updated physical examination of the patient must include any components of the exam that might have changed since the prior history and physical examination. This information must confirm the necessity for admission or any other services rendered and it should be recorded in the patient's file.

Documentation Requirement

• Information must be documented and included within the patient's file through progress or consultation notes prior to surgery or within 24 hours of admission. John Rosing of HCPro suggests including a checkbox and space for notes within your H&P examination form that can be included in the patient's file.