Does a pregnant woman's prenatal record suffice as a history and physical if she needs to have a C-section, or does a separate H&P need to be completed by the physician prior to the surgery?
JCAHO standard PC.2.120, EP6 states that the history and physical must have been completed within 30 days before the patient was admitted or readmitted.
According to the FAQs on the Joint Commission web site a patient's prenatal course of care is planned with the history and physical performed at the first prenatal visit and subsequently updated throughout the pregnancy. The FAQ goes on to say that the entire prenatal record can be used as the history and physical as long as the prenatal record is updated to reflect the patient's condition at the time of admission.
JCAHO FAQ, H&P Older Than 30 Days/Using the Prenatal Record, Revised January 1, 2004Tweet