Documentation and Coding for Patient Safety Indicators
General Documentation Rules & Guidelines. 1. General – ... Inpatient History and Physical (H&P) Requirements- (JCAHO PC 2.120) A physical exam and medical history must be done no more than 30 days before or within 24 hours after an admission for each patient by the attending physician.In order for H&P’s to be transcribed and available in ... ................
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