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.