FEDERALLY FUNDED PATIENTS: DOCUMENTATION REQUIREMENTS

I. HOSPITAL SETTING, Inpatient Care

A. History and physical examination, performed no more than 30 days prior to admission or written forty-eight hours after admission which includes the following:

(1) History to include	(2) Physical exam to include assessment of the following:
*presenting diagnosis/condition	*vital signs
*description of symptoms	*EENT
*significant past medical history	*cardiovascular system
*current medications	*respiratory systems
*any drug allergies	*gastrointestinal system
*proposed procedure(s) (if any)	*genitourinary system
*significant family history	*neurological system
*significant review of systems

B. Admitting diagnosis (reason for admission/readmission)

C. Plan for treatment/diagnostic testing (if admission is for diagnostic testing only, specify why it cannot be done as an outpatient).

D. Results of all consultative evaluations of the patient and appropriate findings by clinical staff involved in the care of the patient.

E. Documentation of all complications, co-morbid conditions, hospital acquired infections, and unfavorable reactions to drugs and anesthesia. Record should include documentation by physician addressing the conditions identified.

F. Properly executed informed consent forms for procedures and treatments specified by the medical staff, or by Federal or State law if applicable, which require written patient consent.

G. All practitioners’ orders, nursing notes, treatment reports, medication records, radiograph/imaging reports, laboratory reports, vital sign recordings, and any other information necessary to monitor the patient’s condition.

H. Physician acknowledgment of all abnormal lab work. Documentation should include recognition of any abnormal values, any treatment given, or rationale why treatment is not indicated.

I. Discharge planning starts at the time of admission. The discharge plan and summary should address the unique needs of the patient and include post-operative instructions and plans for follow-up care, as indicated. The physician discharge summary should include any tests not reported at time of discharge, and plan to follow-up with test results or that the test results are no longer needed. All diagnoses established and treated during the hospitalization must be recorded.

J. All diagnoses established and treated and all invasive procedures are recorded on the physician attestation completed by HIM. The attestation no longer needs to be signed by the physician, but will continue to be filed in the record.

K. Within 30 days of discharge the medical record must be complete.

II SURGICAL OR INVASIVE PROCEDURES PROVIDED IN AN AMBULATORY SURGICAL CENTER (ASC) OR IN A HOSPITAL OUTPATIENT DEPARTMENT (HOPD) INCLUDING OBSERVATION CLASSIFICATION

All records should document the following:

A. History and physical examination, performed no more than 30 days prior to performance of procedure which should include the following:

(1) History to include	(2) Physical exam to include assessment of the following:
*presenting diagnosis/condition	*vital signs
*description of symptoms	*EENT (if applicable)
*significant past medical history	*cardiovascular system
*current medications	*respiratory systems
*any drug allergies	*gastrointestinal system
*proposed procedure	*genitourinary system
*indications for the procedure	*neurological system

B. Results of all consultative evaluations of the patient (if any) and appropriate findings by clinical staff involved in the care of the patient.

C. Documentation of all complications and unfavorable reactions to drugs and anesthesia. Record should include documentation by physician which addresses the complications/conditions identified, as well as treatment given.

D. Properly executed informed consent forms for procedures and treatments specified by the medical staff, or by Federal or State law if applicable, which require written patient consent.

E. Operative/procedural note which includes type of anesthesia (i.e., general, regional, or local), findings, and description of operation/procedures performed.

F. All practitioners’ orders, nursing notes, treatment reports, medication records, radiograph/imaging reports, laboratory reports, vital sign recordings and any other information necessary to monitory the patient’s condition, or necessity of procedure.

G. Physician acknowledgment of all abnormal lab work. Documentation should include recognition of any abnormal values, any treatment given, or rationale why treatment is not indicated.

H. The discharge plan diagnosis should address the medical stability of the patient at discharge and the unique needs of the patient and include post- operative instructions and plans for follow-up care, as indicated. All diagnoses established and treated must be recorded.

I. Within thirty days after discharge, the medical record must be complete.

NOTE: The facility in which the service is performed (ASC or HOPD) is responsible for assuring that all documentation regarding the patient’s condition is available in the medical record. For reports that are not easily transferable, the physician must clearly document the results of the tests, exams, radiographs, etc.

III SERVICES PROVIDED IN EMERGENCY ROOM OR MEDICAL TREATMENT PROVIDED IN A HOSPITAL OUTPATIENT DEPARTMENT (HOPD) (FOR SURGICAL/INVASIVE PROCEDURES SEE ASC/HOPD DOCUMENTATION GUIDELINES) INCLUDING OBSERVATION CLASSIFICATION

All records should document the following:

A. History and physical examination (intake assessment), performed no more than 30 days prior to provision of services, which should include the following:

(1) History to include	(2) Physical exam to include assessment of the following:
*presenting diagnosis/condition	*vital signs (if indicated)
*description of symptoms	*EENT (if indicated)
*significant past medical history	*cardiovascular system (if indicated)
*current medications	*respiratory systems (if indicated)
*any drug allergies	*gastrointestinal system (if indicated)
*proposed treatment	*genitourinary system (if indicated)
(medical or teaching)	*neurological system (if indicated)
	*treatment site (or type)

B. Results of all consultative evaluations of the patient (if any) and appropriate findings by clinical staff involved in the care of the patient.

C. Documentation of progress of treatment, all complications and unfavorable reactions to drugs and anesthesia. Record should include documentation by physician which addresses the complications/conditions identified.

D. Properly executed informed consent forms for procedure and treatments specified by the medical staff, or by Federal or State law if applicable, which require written patient consent.

E. All practitioners’ orders, nursing notes, treatment reports, medication records, radiograph/imaging reports, laboratory reports, vital sign recordings, and any other information necessary to monitor the patient’s condition, or necessity of procedure.

F. Physician acknowledgment of all abnormal lab work. Documentation should include recognition of any abnormal values, treatment given, or rationale why treatment is not indicated.

G. The discharge plan and discharge diagnosis should address the unique needs of the patient and include discharge instructions and plans for follow-up care, as indicated. All diagnoses established and treated must be recorded.

H. Within thirty days after discharge, the medical record must be complete.

NOTE: The facility in which the service is performed (Hospital Outpatient Department) is responsible for assuring that all documentation regarding the patient’s conditions is available in the medical record. HOPDs, clinics, and the physician offices must work together to accomplish this task. For reports that are not easily transferable, the physician must clearly document the results of the tests, exams, radiographs, etc. in the patient’s history.