Completion of history and physical examination bylaws language
The Centers for Medicare & Medicaid Services requires medical staff bylaws to address who can perform the history and physical examination and in what time frame the history and physical exam must be completed. The Joint Commission also adopted this requirement in 2009. The following is sample bylaws language that addresses the completion of history and physical examination:
A medical history and physical examination must be completed no more than 30 days before or 24 hours after admission or registration, but prior to surgery, an interventional diagnostic procedure, or a procedure requiring anesthesia services. The medical history and physical examination must be completed and documented by a physician, an oral/maxillofacial surgeon, or other qualified licensed individual in accordance with state law and hospital policy.
An updated examination of the patient, including any changes in the patient’s condition, must be completed and documented within 24 hours after admission or registration, but prior to surgery, an interventional diagnostic procedure, or a procedure requiring anesthesia services, when the medical history and physical examination is completed within 30 days before admission or registration. The updated examination of the patient, including any changes in the patient’s condition, must be completed and documented by a physician, an oral/maxillofacial surgeon, or other qualified licensed individual in accordance with state law and hospital policy.