jmartos_mod2policytemplate_021818.docx

jmartos_mod2policytemplate_021818.docx - Rasmussen Medical...

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Rasmussen Medical Center Policy: Health Record Documentation Requirements Approval Date: xx/xx/xxxx Policy Group: Medical Staff Bylaws All medical staff and health care providers shall: 1. All Medical History and Physical Examination are required within 24 hours post admission of before surgery. If it can not be completed before surgery, the physician must document the patient’s medical condition in the progress notes prior to surgery. For Elective admis- sions, the medical H&P can be completed no more than 7 days prior to admission. Components of the medical history are chief complaint, present illness, past medical history, social and personal history, family medical history and a review of systems such us respira- tory system, neurological system, musculoskeletal system, cardiovascular system etc. Components of the Physical Examination are general condition, vital signs, skin, head, eyes, ears, nose and sinuses, mouth, throat, neck, thorax (anterior and posterior), breasts, lungs,
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