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Jan 9, 2024

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Cedar Bend H&P Documentation Amanda Grogan Student ID 00378130 Pennsylvania

PA & TJC H&P Standard similarities PA TJC Documentation must be completed by a qualified Physician or NP Must be completed by a qualified Physician or state designated individual H&P must be completed either electronically or a handwritten chart written within 24 hours of admission H&P must be completed within 24 hours of admission Prior to any surgery with anesthesia Prior to any surgery with anesthesia (Pennsylvania code, 2023) (P, Oach & A, Watters, 2020)

PA and TJC H&P differences PA TJC TB test is required yearly No requirement for TB tests Nurses are able to sign off on vaccinations, TB tests and vision/hearing exams Only a qualified physician is specified Notes from staff, Nurses and specialized personal will be included No mention of notes from other staff other than the qualified physician completing the H&P Pathological, Radiology and therapeutic procedures and reports are included in the H&P Only labs are mentioned in TJC requirements and only for the main diagnoses (Pennsylvania code, 2023) (P, Oach & A, Watters, 2020)

Social and Personal History • Including social history allows for an overall and complete picture of the patient. Some patients have behaviors specific to social environments. • Including social history allows for habits such as smoking, drinking and drugs to be evaluated and documented thoroughly. • Personal history can form a better picture of habits, trends in self care and medical history. It also tells a story about the patients current medical standing. • Both social and personal history impact any current illnesses. (P, Oach & A, Watters, 2020)

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