Question: We understand that CMS and the Joint Commission are now requiring the inclusion of information on Histories and Physicals (“H&Ps”) in the Medical Staff Bylaws. Does this mean we have to include all information on H&Ps in the Bylaws or can we put some of the details in the Medical Staff Rules and Regulation and other policies?
Answer: We recommend moving all provisions regarding H&Ps from the Rules and Regulations to the Bylaws. We make this recommendation to avoid duplication and the possibility of inconsistencies between the Bylaws and Rules and Regulations that could arise over time because one document is revised and the other is not.
However, the Medicare Conditions of Participation (“CoPs”) and Joint Commission Accreditation Standards do not require inclusion of information for short stays and reassessments and consults, etc. in the Bylaws if this information is included in Rules and Regulations.
The CoPs, at 42 C.F.R. §482.22(c)(5), state that the Bylaws must include a requirement that:
(i) A medical history and physical examination be completed and documented for each patient no more than 30 days before or 24 hours after admission or registration, but prior to surgery or a procedure requiring anesthesia services. The medical history and physical examination must be completed and documented by a physician…, an oromaxillofacial surgeon, or other qualified licensed individual in accordance with State law and hospital policy.
(ii) An updated examination of the patient, including any changes in the patient’s condition, be completed and documented within 24 hours after admission or registration, but prior to surgery or a procedure requiring anesthesia services, when the medical history and physical examination are completed within 30 days before admission or registration. The updated examination of the patient, including any changes in the patient’s condition, must be completed and documented by a physician…, an oromaxillofacial surgeon, or other qualified licensed individual in accordance with State law and hospital policy.
Thus, the implication is that only the details required in the quoted language are required to be included in the Bylaws.
The Joint Commission, in MS.01.01.01, E.P. 16 and PC.01.02.03, E.P.s 4 and 5, mirrors the requirements in the CoPs, but states that the requirements for H&Ps in the Bylaws should be included in accordance with MS.01.01.01, E.P. 3, which permits “associated details, some of which may be extensive” to reside in the Rules and Regulations or other policies. An FAQ published in March 2011 by the Joint Commission is consistent with this and provided as follows:
Question: EP 16 provides that the ‘requirements’ for performing histories and physicals (H&P) must be in the bylaws. Does that mean that the bylaws must now contain all the details regarding the required contents of an H&P, which are commonly found in medical staff rules or a medical record policy?
Answer: CMS CoPs (Section 482.22(c)(5)) require that the medical staff bylaws contain the requirements for completing and documenting an H&P that must be completed for each patient. EP 16 was included to align Joint Commission requirements with CMS requirements which include information on who can perform an H&P and the time frame (e.g., not more than 30 days prior to and within 24 hours after admission; requirements for H&P updates; requirements for H&P outpatient procedures; and any countersignature requirements). Requirements for other information or details, such as the medical history, psychological history, body systems review, etc., can be placed in other documents (rules, regulations, or policies) if desired.
Therefore, while we recommend that all provisions relating to H&Ps be included in the Bylaws to avoid duplication and possible inconsistencies, the CoPs and Joint Commission Accreditation Standards do not require this, as long as the requirements outlined in 42 C.F.R. §482.22(c)(5) are included in the Bylaws.