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MEC Update - History and Physical Compliance

History and Physical (H&P) Compliance Plan Approved

A patient's history and physical (H&P) examination must be dictated or written within 24 hours of admission. In an effort to ensure 100 percent compliance, the MEC approved a plan on February 4 to begin daily monitoring of patient charts for H&Ps within 24 hours of admission or before surgery.

If no H&P is found, a representative from the Health Information Department will contact the responsible physician by telephone or e-mail, notifying them of non-compliance and requesting them to correct the deficiency immediately. In addition, the physician's clinical chief or department chair will be notified.

Once notified, the physician will then need to dictate their H&P in the next 24 hours. Written H&Ps will not be accepted at that point; they must be dictated.

Beginning Monday, March 17, if a physician is contacted regarding non-compliance and does not resolve the problem within 24 hours, he or she will be put on medical staff administrative suspension (added to the daily medical records suspension list). Physicians on administrative suspension will not be permitted to schedule elective admissions or surgery.

Monitoring of patient charts for H&Ps will be conducted on weekdays and weekends. However, if a non-compliant H&P is found on a weekend, physician notification will not take place until the following Monday.

For more information about H&P Compliance, please contact the Health Information Department at (310) 423-2259 or Scott Karlan, M.D., director of the Health Information Committee, at scott.karlan@cshs.org.