Question

As a concurrent record reviewer for an acute care facility, you have asked Dr. Crossman to provide an updated history and physical for one of her recent admissions. Dr. Crossman pages through the medical record to a copy of an H&P performed in her office a week before admission. You tell Dr. Crossman
- a new H&P is required for every inpatient admission
- that you apologize for not noticing the H&P she provided
- the H&P copy is acceptable as long as she documents any interval changes
- Joint Commission standards do not allow copies of any kind in the original record

Answer 1

As a concurrent record reviewer for an acute care facility, you have asked Dr. Crossman to provide an updated history and physical for one of her recent admissions. Therefore, You tell Dr. Crossman to option C: the H&P copy is acceptable as long as she documents any interval changes.

What is a concurrent chart review?

In a concurrent coding review process, coders examine the EHR/medical notes and HCC codes in real time before the claims are sent to payers. Coders frequently make use of the EHR and RCM technology already in place to make this kind of review possible.

Therefore, note that the written record of a patient encounter includes the History, Physical Exam, Assessment, and Plan; it is frequently abbreviated as "H&P" for History and Physical.

Hence, in the above case, the History and Physical Exam, or "H&P," is where the patient's "story" about why they sought medical attention or are currently receiving medical attention begins.

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