From HIM: Vital signs ARE an H&P documentation rule

11 Jun 2017

By: Gena Inches, HIM manager

 

To address recent questions, HIM has clarified that vital signs must be documented. The Salem Health Medical Staff rules align with CMS and Joint Commission H&P documentation requirements.

To customize your template to add required H&P elements, place a request with the Solution Center at 503-814-4357.

H&P requirements listed in SH Medical Staff R&R (pages 11-12):  

• Chief complaint
• Details of present illness (reason for hospitalization)
• Presence of significant allergies or documentation of none
• Current medications which are pertinent to the reason for admission or procedure
• Physical examination, including vital signs
• Impression, differential diagnosis, conclusion
• Treatment
• Plan

H&P update requirements:

• H&P reviewed
• Patient examined
• Document if there are no changes or changes noted