Medical Staff Bylaws - Arkansas Children's Hospital

4.2.6 Active Medical Staff 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. Medical 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