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Question

Joint Commission and Medicare CoP

Guidelines (Slide 3 of 4)

• The Joint Commission standards and Medicare CoP state that the history and physical examination must

be performed and documented in the patient record within 24 hours after admission (including weekends

and holidays). If a history and physical examination (H&PE) was completed within 30 days prior to

admission and reviewed and updated, it can be placed on the record within 24 hours after admission.

Medicare CoP requires a final diagnosis with completion of medical records within 30 days following patient

discharge.

• Medicare CoP state that all physician order entries must be legible, complete, authenticated (name and

discipline), dated, and timed promptly by the prescribing practitioner in electronic or written form. If

permitted by facility bylaws (policies), it is also acceptable for another practitioner responsible for the care

of the patient to authenticate the order, even if the order did not originate with that practitioner.

• Medicare CoP state that all records must contain written patient consent for treatment and procedures

specified by the medical staff, or by federal or state law.

Answer

Joint Commission and Medicare CoP require history and physical examination to be performed and documented within 24 hours after admission, or within 30 days prior to admission if reviewed and updated. A final diagnosis and completion of medical records must be done within 30 days following patient discharge. Physician order entries must be legible, complete, authenticated, dated, and timed promptly. Written patient consent for treatment and procedures specified by medical staff or law must be included in all records.

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The Joint Commission and Medicare CoP guidelines are important standards that healthcare facilities must follow to ensure quality patient care and safety. One of the requirements is that a history and physical examination must be performed and documented within 24 hours after admission, including weekends and holidays. This is to ensure that the patient's medical condition is properly assessed and documented, and that any necessary treatment can be initiated promptly. If a history and physical examination was completed within 30 days prior to admission and reviewed and updated, it can be placed on the record within 24 hours after admission. This is to avoid unnecessary duplication of tests and procedures, and to ensure that the patient's medical history is accurately documented. Medicare CoP also requires a final diagnosis with completion of medical records within 30 days following patient discharge. This is to ensure that the patient's medical condition is properly documented and that any necessary follow-up care can be provided. Physician order entries must be legible, complete, authenticated (name and discipline), dated, and timed promptly by the prescribing practitioner in electronic or written form. If permitted by facility bylaws (policies), it is also acceptable for another practitioner responsible for the care of the patient to authenticate the order, even if the order did not originate with that practitioner. This is to ensure that the patient's treatment plan is properly documented and that any necessary medications or procedures are administered in a timely and accurate manner. Finally, all records must contain written patient consent for treatment and procedures specified by the medical staff, or by federal or state law. This is to ensure that the patient is fully informed about their treatment options and that their rights are protected.