Wiki H&P requirements

[diann]

We are having a discussion with our providers about the following scenario:

Pt admitted to Observation from ED. Same provider does the ED and writes an H&P for the Observation. Than the next day same provider/or provider from same practice admits the pt to Acute care. Patient is later discharged on a different day.

Question: if the H&P is used as the Observation note for that day, can it also be used for the Acute admit on the following day. Since the H&P has to be done within 24 hours, doesn't the H&P for an Acute stay start with the Acute admit date/time order.

They say the H&P should be allowed to cover the Observation and Acute admit. I am saying that the ED report can be used for the Observation admit but if they do the H&P on the Observation admit day than that day it is tied to that date's note. I say the H&P can't be used for both dates. It's double dipping. Am I wrong?

Thanks
Diann DoBran CPC, COC

 

[alisonatrammell]

As long as the patient's condition remains the same with no major change in status/condition, the H&P may be used (it may also be used on another admission to the facility within 30 days as long as there are no changes to the patient's condition). The same goes for a H&P done in the physician's office and the patient is sent for admission (also as long as it is within the 30 day timeframe). No change, no new H&P needed. Noted significant change, new H&P.

Make sense??