Registered Health Information Administrator (RHIA) — Question 149

As a concurrent record reviewer for an acute care facility, you have asked Dr. Crossman to provide an updated history and physical for one of her recent admissions. Dr. Crossman pages through the medical record to a copy of an H&P performed in her office a week before admission. You tell Dr. Crossman.

Answer options

• A. a new H&P is required for every inpatient admissions.
• B. that you apologize for not noticing the H&P she provided.
• C. the H&P copy is acceptable as long as she documents any interval changes.
• D. Joint Commission standards do not allow copies of any kind in the original record.

Correct answer: C

Explanation

The correct answer is C because it allows for the use of a prior H&P as long as Dr. Crossman documents any relevant changes since the last examination. Option A is incorrect because a new H&P is not always mandatory if documentation is sufficient. Option B is irrelevant as it does not address the requirements for the H&P. Option D is false since Joint Commission standards permit copies under certain conditions.