Question: We are revising our Bylaws and, to comply with federal regulations and accreditation standards, are moving the requirements for histories and physicals from the Medical Staff Rules and Regulations to the Bylaws.  In doing so, a question came up from the Medical Staff regarding what exactly is required for inclusion in a “complete medical history and physical examination”?

Answer: While there is no definitive instruction on what a complete history and physical examination must include, we recommend as a best practice including the following:  patient identification, chief complaint, history of present illness, review of systems, personal medical history and family medical history, social history, physical examination, data review, assessments, plan of treatment, and any signs of abuse, neglect, or addiction.  This allows for a comprehensive, well?documented history and physical, which (1) assists in obtaining an accurate diagnosis; (2) demonstrates that the history and physical was thorough (which will insulate against malpractice claims); and (3) informs the plan of care and any follow-up treatment.

The Joint Commission only requires that the Medical Staff specify the minimal content of histories and physicals.  Thus, the Joint Commission leaves the minimal content of histories and physicals to the discretion of the Medical Staff.  However, the Joint Commission’s Glossary provides some insight on expectations for histories and physicals.  In that Glossary, “history and physical” is defined as follows:

Information gathered about an individual using a holistic approach for the purpose of establishing a diagnosis and developing a plan for care, treatment, and services to address physical health issues. The history may include information about previous illnesses, previous medical or surgical interventions and response to treatment, family health history, and social, cultural, economic, and lifestyle issues that may affect the individual’s health and well-being. The physical involves the physical examination of the individual’s body by the following means: inspection, palpation, percussion, and auscultation. When used in concert with behavioral health care services, the history and physical may be used to rule out physical causes for behavioral health conditions or to assess the impact of a medical diagnosis or treatment on a behavioral health condition.

Hospitals may also want to check with insurers to determine if reimbursement is dependent on any specific requirements for histories and physicals.  Medicare billing rules on this particular topic are silent.  Some commercial insurers, on the other hand, have stringent requirements for history and physical documentation.  For example, some Blue Cross/Blue Shield products require history and physical documentation to include pertinent information such as age, height, vital signs, past medical and behavioral history, family history, and preventive health maintenance and risk screening.