outpatient procedure provided a Medical Staff Member privileged to do H & Ps at Renown :
( 1 ) reviews and validates the H & P prior to the procedure ; ( 2 ) writes an update in a progress note prior to the procedure ; and
( 3 ) agrees to be accountable for the content of such H & Ps and acknowledges this accountability by :
( a ) countersigning and dating the H & P documentation prior to the procedure ; and
( b ) documenting , within twenty-four ( 24 ) hours of admission and prior to any surgery or procedure , in a progress note that the Medical Staff member has interviewed and examined the patient and that he / she agrees with the information in the H & P or disagrees with it , noting the differences . d .
A podiatrist or dentist who is an Active Medical Staff Member may perform and document the history , physical findings , initial diagnostics , assessment and plan which are limited to a patient ’ s podiatric and dental care respectively . This information :
( 1 ) may be included or referred to in the H & P performed by a Medical Staff Member ; and
( 2 ) need not be countersigned by another Active Medical Staff member . e .
A podiatrist or dentist who is an Active Medical Staff Member may also apply for and be granted special privileges to perform complete histories and physicals in all inpatient and outpatient settings – provided the podiatrist or dentist can provide documentation that she / he has the appropriate training and experience to do so .
B . 7 .
All H & Ps must be typed , dictated or electronically generated with the following exceptions :
a .
An abbreviated History and Physical Examination may be completed in legible handwriting and used temporarily as an H & P in situations wherein an H & P needs to be completed and placed in the Medical Record prior to a emergent / urgent surgery or invasive procedure ; however , a dictated or electronically generated H & P should be completed and placed in the medical record no more than twenty-four ( 24 ) hours after the admission or outpatient procedure ;
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