Medical Staff Bylaws - Arkansas Children's Hospital
Medical Staff Bylaws - Arkansas Children's Hospital
Medical Staff Bylaws - Arkansas Children's Hospital
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4.2.6 Active <strong>Medical</strong> <strong>Staff</strong> are responsible for History and Physical Examinations (H&P). Acomplete admission history and physical examination will be recorded within 24 hours after admissionbut prior to surgery or a procedure requiring anesthesia.4.2.6.1 The H&P shall include, at a minimum, the following information for allinpatient admissions.1. Chief complaint, reason for the admission or procedure, description of present illness2. <strong>Medical</strong> history (including past and present diagnoses, illnesses, operations,medications, and allergies), family history, age-appropriate social/developmentalhistory3. Full review of systems and relevant physical findings4. Documentation of medical decision-making including a review of diagnostic testresults; response to prior treatment; assessment, clinical impression or diagnosis; planof care; evidence of medical necessity and appropriateness of diagnostic and/ortherapeutic services; counseling provided, and coordination of care4.2.6.2 A focused H&P examination may be used for non-complex outpatienttreatments or procedures on non-complex patients that do not require general anesthesia. The focusedH&P examination report should, at a minimum, include the following:1. Chief complaint or reason for the procedure;2. A problem-focused history; past medical history including allergies and currentmedications;3. Physical examination including an examination of the heart and lungs and the affectedbody area necessitating the outpatient treatment or procedure; pertinent laboratory orradiologic testing results;4. Clinical impression and plan of care.4.2.6.3 When using an H & P that was completed within 30 days before admission, anupdate documenting any changes in the patient’s condition is completed within 24 hours after admission,but prior to surgery or a procedure requiring anesthesia services. The update must include a statementthat the patient was examined and any changes noted during this exam. When an H&P older than 24hours is used, a legible copy of the H&P must be placed in the patient's hospital medical record.5