C
MS and other authorities
require history and
physical forms
to be completed within
30 days before surgery. At
most facilities and for most
cases, that's not a problem.
But a busy orthopedic surgery
schedule sometimes means
patients have to wait a few
weeks between their pre-op office
visit and their procedure. And some states, ours for one, require H&P
completion within 7 days of surgery. That double bind can put you
under the gun with regard to H&P compliance. However, here's a solu-
tion — approved by the AAAHC surveyors who have seen it in action
at our facility — that will keep your staff from having to needlessly re-
write the entire H&P on the day of surgery.
If the patient's condition hasn't changed since the assessment, the
surgeon can write "NO CHANGES" on the front of the H&P, along with
the current date and his signature to bring the form into compliance.
One of our surgeons even ordered his own "NO CHANGES FROM PREVIOUS
H&P" rubber stamp to save a few seconds. And the H&P form pro-
grammed into our EMR system includes a "NO CHANGES" checkbox
with a space for initials and the date.
Susan Stanfield, RN, BS
Institute of
Orthopaedic Surgery
Las Vegas, Nev.
sstanfield@ios.lvcoxmail.com
2 4 • O U T PA T I E N T S U R G E R Y M A G A Z I N E • M A Y 2 0 1 6
No Need to Rewrite Unchanged
• REDUCE REDUNDANCY Don't
rewrite outdated H&Ps if nothing has
Ideas Work
That
