Do we have to put our entire H&P language into the bylaws?

I repeatedly hear questions about how much history and physical examination (H&P) language needs to be in bylaws as I consult with medical staffs around the country. This question stems from confusion over Joint Commission standard MS.01.01.01, EP 20 which states that hospitals that use Joint Commission accreditation for deemed status must include in their bylaws requirements for completing and documenting medical histories and physical examinations. The H&Ps must be completed and documented by a physician, an oromaxillofacial surgeon, or other qualified licensed individual in accordance with state law and hospital policy.

Many organizations fear that they must put the entirety of their H&P language, which currently resides in the rules and regulations or in policy format, back into the bylaws. However, if you don’t over-interpret the standard, there is no reason to get nervous.

MS.01.01.01, EP 20 addresses the requirements for completing the H&P, which may be interpreted as the timeframes in which an H&P must be performed, including any updates to the H&P. The standard also addresses which types of practitioners may perform the H&P, and that varies from state to state and organization to organization.

Our advice is to keep the minimum required information on H&Ps in the bylaws, since bylaws are harder to amend than policies and procedures or rules and regulations. Keep the bulk of your H&P material in your policies and procedures or rules and regulations. Here is some sample language that you may adapt to fit your facility’s needs:

According to medical staff and hospital policies, each practitioner shall prepare and complete in a timely fashion the medical and other required records for all patients to whom the practitioner provides care in the hospital, or within its facilities, clinical services, or departments.

1. A medical history and physical examination shall be completed no more than 30 days before or 24 hours after admission or registration, but prior to surgery or a procedure requiring anesthesia services. The medical history and physical examination must be completed and documented by a physician, an oromaxillofacial surgeon, or other qualified licensed individual in accordance with state law and hospital policy.
2. When the medical history and physical examination is completed within 30 days before admission or registration, the physician must complete and document an updated examination of the patient within 24 hours after admission or registration, but prior to surgery or a procedure requiring anesthesia services. The updated examination of the patient, including any changes in the patient’s condition, must be completed and documented by a physician, an oromaxillofacial surgeon, or other qualified licensed individual in accordance with state law and hospital policy.
3. The content of complete and focused history and physical examinations is delineated in the rules and regulations.
    

Mary Hoppa, MD, MBA, CMSL, is a senior consultant with The Greeley Company, a division of HCPro, Inc. in Marblehead, MA.