Renown - Medical Staff Rules and Regulations - 12-23-24 | Page 15

1.
Chief complaint;
2.
History of the present illness including any prior treatment( s) performed;
3.
Past medical history including allergies and current medications;
4.
Physical examination including vital signs, heart exam, lung exam, and
exam of the pertinent body area;
5.
Pertinent laboratory or radiologic testing results;
6.
Assessment; and
7.
Plan of care.
B.
History and Physical Examination: Per the Medical Staff Bylaws, the following items are the recommended and essential elements for H & Ps. Bold / Underlined elements are essential and required.
1.
patient identification;
2.
chief complaint;
3.
history of the present illness;
4.
review of systems;
5.
personal medical history, including medications and allergies;
6.
family medical history;
7.
social history, including, if applicable, any abuse or neglect;
8.
physical examination, to include pertinent findings in those organ
systems relevant to the presenting illness and to co-existing diagnoses;
9.
data reviewed;
10.
assessments, including problem list;
11.
plan of treatment; and
12.
if applicable, signs of abuse, neglect, addiction, or emotional / behavioral
disorder, which will be specifically documented in the physical
examination, and any need for restraint or seclusion which will be
documented in the plan of treatment.
B. 1.
An H & P containing at least the essential elements noted above must be documented in the medical record of a patient prior to the patient undergoing the following inpatient or outpatient procedures:
a. all procedures performed in the Operating Room( OR); b. coronary angiography; c. peripheral angiography.
B. 2.
All patients undergoing inpatient or outpatient procedures requiring general anesthesia, moderate sedation or deep sedation must have one of the following documented in their medical records prior to starting those procedures:
a. an H & P containing at least the essential elements noted above; or
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