Time Frames for History and Physicals (H&Ps)

  1. Dictated History and Physicals (H&Ps) using the current Health Information Management (HIM) dictation service or H&Ps created in PowerNote through Dragon or typed text must be in the Electronic Medical Record (EMR) within 24 hours after admission or prior to surgery/procedures.
  2. Not more than 30 days old
  3. H&P Update must be completed prior to the procedure using the H&P Update Template (PowerNote) that contains the approved language in one of two ways:
    • If there are changes, the physician can document those changes directly into the note. 
    • If there are no changes in the H&P, the physicians can use the Update Template and paste it onto the bottom of the actual H&P.