Renown South Meadows Rules & Regulations | 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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