The Centers for Medicare & Medicaid Services made a change effective Nov. 29, 2019, indicating that healthy outpatients may not be required to have a history and physical. This event will outline the policy, medical staff and board approval, revised medical staff bylaws, and more.

Attendees of this program will learn what is required to be in the H&P and how to meet compliance with the CMS hospital Conditions of Participation, The Joint Commission and DNV standards. CMS has five sections addressing H&Ps for acute and critical access hospitals, and hospitals must ensure their policies and procedures meet the requirements. Medical staff by-laws also must comply with the regulations and interpretive guidelines and standards. Information on medical records deficiencies, as well as what CMS identifies during a medical record review, will be covered.

Learning Objectives:-

• Recall that CMS has five H&P requirements in the hospital conditions of participation that all hospitals that accept Medicare must follow
• Discuss that the Joint Commission has standards on H&P 
• Recall that CMS issued clarification changes for hospitals on H&Ps in a CMS survey and certification memo
• Describe that the hospital must have medical staff by-laws and policies that include the requirements for H&Ps
• Discuss what hospitals have to do to implement the new rule that H&Ps do not need to be done on healthy outpatients

Detailed Outline:-

Introduction to the CMS hospital CoP requirements

• CMS current hospital CoP manual
• How to locate changes
• Tag 358  and 359 on H&P in the Medical Staff section
• Tag 461 and 463 on H&P in the Medical Records section
• Tag 952 in surgery services
• The new exception for healthy outpatients
• How to draft a policy for the new exception
• How to process the issue and MS and Board approval
• Medical staff by-laws
• 24-hour update rule and the 30-day rule
• Updates on the day of surgery or procedure requiring anesthesia
• What constitutes anesthesia
• H&P on the chart before surgery
• Exceptions for emergencies
• Who can perform
• When is an H&P required?
• Documentation in the medical record
• H&P done by the non-credentialed practitioner
• CMS clarification memo
• CAH requirements and new tag numbers in 2020

The Joint Commission H&P standards

• Medical staff chapter
• Record of care chapter standards
• Provision of care chapter standards
• Documenting H&P
• 24 hour and the 30-day rule
• MS by-laws
• Qualified physician and delegation
• FAQ on H&P
• H&P for outpatient procedures
• Medical students doing H&P
• Content of H&P
• Podiatrist doing H&P
• Prenatal record
• Authentication of the H&P
• H&P for outpatient procedures

Who Should Attend?

• Chief  Medical Officer
• Chief Nursing Officer
• OR staff and OR nurses
• Director of HIM
• PAT department staff
• Outpatient nurses and staff
• Surgery nurses
• Chief Risk Officer
• Chief Operating Officer
• MS staff and physicians, PA and NP
• Risk Managers
• Compliance Officers
• Director of Regulatory Affairs
• Outpatient Director
• Hospital legal counsel
• Joint Commission Director
• Director of Health Information Management
• Anyone involved in ensuring compliance with the history and physical requirements from the Joint Commission and CMS hospital conditions of participation