Medical Records Run-Down Blog Series Part 3

History and Physical

You need to determine before the procedure if there is any condition that would affect the planned procedure.  CMS Interpretive Guidelines dictate that you should have a comprehensive history and physical performed on the patient not more than 30 days before the date of the scheduled surgery.  The history and physical must be performed by a physician or other qualified licensed individual in accordance with state law and your surgery center policy on Medical Records.  Click for Medical Record Run-Down Part 1 and Part 2.

Pre-Surgical Assessment

The patient must be examined immediately before surgery per CMS Interpretive Guidelines.  You must evaluate the risk of anesthesia.  The patient must be assessed for any changes prior to the history and physical in which was performed not more than 30 days before the date of the scheduled surgery.  Now, if you provide the patient with a history and physical the day of the procedure you want to ensure that you do not perform the H&P after the patient has been prepped and brought into the operating room for surgery and the pre surgical assessment still has to be performed separately.  It is during the pre-surgical checklist you determine if the patient is on any new medications and/or supplements in the last few days, changes in health or allergic reactions.  This information is very important to log in the medical record.  The surveyors will be looking for this.

For more information please go to the blog roll and download the CMS Interpretive Guidelines.  You can also call me for further assistance.

Here’s to your success,




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