Here are tips for getting H&Ps on the chart
It’s one of those problems that drive same-day surgery managers crazy: getting physicians to put the history and physical (H&P) on the patient’s chart.
In addition to H&P requirements from the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and the Accreditation Association for Ambulatory Health Care, some states, such as Illinois, are requiring the H&P as part of the surgery center licensing requirements. Still, some physicians don’t comply.
LuAnn Montz, an operating room supervisor in Ohio, whose facility name and city are being withheld at her request, described her frustration this way: "No one seems to want to take the responsibility for them. The surgeons say it’s the medical docs’ responsibility, and the medical docs say it’s the surgeon’s. Nursing is once again in the middle.
"The preadmission nurse doesn’t even know who to call to get the H&P. Therefore, we spend hours on the phone trying to figure out just who is responsible for it or who is willing to do it."
To assist readers, we’ve compiled the following suggestions from your peers:
• "If there is not an H&P on the chart, sometimes the anesthesiologist will fill one out," says Debbie Grunwald, RN, CNOR, medical staff coordinator, OR staff nurse, perioperative RN, and recovery discharge nurse at HealthSouth Aurora (CO) Surgery Center. "A dictated H&P on the chart is acceptable."
• "Contact your chief of surgery and see what their policy is," says Dave Pucklavage, RN, staff nurse at Lehigh Valley Hospital in Allentown, PA. "And if they do not have one, make them write one."
Your hospital should have guidelines’
• "Your hospital [policies and procedures] should have guidelines for H&Ps," says Sandy Bean, BSN, RN, CNOR, Clinical Nurse II at University of California, Davis Medical Center in Sacramento. "If it doesn’t, try going through your medical staff committee. It is ultimately the physician’s responsibility to make sure a history and physical is available. We all know what will happen if a patient suffers an adverse reaction because some important detail was omitted that would have been on an H&P."
No surprises here
• "In order to comply with the Joint Commission requirements, we had to take a hard line on the H&Ps," says Sharon N. Smith, RN, CNOR, clinical coordinator at Methodist Hospital main operating room in Sacramento.
"Fortunately, that piece is in the medical staff bylaws, and we just said Gee doc, I’m sorry, but we can’t take your patient into the room unless there is an H&P on the chart.’ I put up BIG signs in the locker room and the lounge area, so it did not come as a surprise that we would be enforcing the rule.
"We reminded them that they could fax the H&Ps ahead of time we called the offices, too and we would hold them until the day of surgery. Some of the doctors still write the H&P when they arrive, but the patient stays in the holding area until they are finished. The Outpatient Surgery Center does the same thing. We would have liked to have the H&Ps on the chart before the patient came to surgery, so that we could review the findings, but have had to adopt a compromise.
"If a physician becomes unruly’ because we are enforcing the bylaws, we will take the patient into the room, but I write a notification [incident] report, and it is handled by the surgery committee."
A slow but successful process
• "Here in Saginaw, MI, we do not take the patient into the OR until we have an H&P on the chart," says Linda Rowe, RN, BSN, CNOR, clinical nurse specialist of surgical services at Saginaw General Hospital. "Many letters and discussions at medical staff meetings have occurred in the recent past to make this happen. It was a slow process; however, with the help of JCAHO recommendations and our persistence, we now have H&Ps on the charts."
"Handwritten H&Ps are pitiful. [You] can’t read them, and they’re not comprehensive," says Mary McClure Ritchie, RN, CNOR, clinical staff nurse IV at Summit Medical Center in Oakland, CA. "Have the surgeons fax the H&Ps instead of hand-delivering them. Be sure to copy the fax, since I heard faxes fade over time."
The final solution? "Strong and continuous administrative support," Ritchie says.
[Editor’s note: Do you have a nagging problem that you’d like help with? Use Same-Day Surgery as your free consulting source! Send us your questions, and we’ll get input from your peers. Contact: Joy Daughtery, Managing Editor, Same-Day Surgery, P.O. Box 740056, Atlanta, GA 30374. Telephone: (404) 262-5420. Fax: (404) 262-7837. E-mail: joy_ [email protected].]
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