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H & P Reminder

Pre-op assessments must be within 30 days

Physicians are reminded that history and physical (H & P) exams must be documented no more than 30 days prior to surgery or a procedure.

The timeframe applies to every patient scheduled for an inpatient or outpatient invasive procedure, or a non-invasive procedure that may result in a significant physiological effect. Following the guidelines is not dependent on anesthesia being administered.

The H & P can be dictated or written in the 30-day pre-op period by a physician with appropriate privileges or by a physician-in-training.

If dictated, it should be coded as "Pre-op." A "STAT" transcription is necessary if the assessment is dictated the day before surgery to ensure its availability by 5 p.m. that day.

Click here to download a PDF of Cedars-Sinai's Pre-Operative Testing Guidelines for Adults.