Ohio Administrative Code|Rule 3335-43-11 | History and physical.

                                                
(A) History and physical
		  examination.
(1) A history and
			 physical appropriate to the patient and/or the procedure to be completed shall
			 be documented in the medical record of all patients either:
(a) Admitted to the hospital
(b) Undergoing outpatient/ambulatory procedures
(c) Undergoing outpatient/ambulatory surgery
(d) In a hospital-based ambulatory clinic
(2) For patients admitted
			 to the hospital, the history and physical examination shall include at a
			 minimum:
(a) Date of admission
(b) History of present illness, including chief
				complaint
(c) Past medical and surgical history
(d) Relevant past social and family history
(e) Medications and allergies
(f) Review of systems
(g) Physical examination
(h) Test results
(i) Assessment or impression
(j) Plan of care
(3) For patients
			 undergoing outpatient/ambulatory procedures or outpatient/ambulatory surgery,
			 the history and physical examination shall include at a minimum:
(a) Indications for procedure or surgery
(b) Relevant medical and surgical history
(c) Medications and allergies or reference to current listing in
				the electronic medical record
(d) Focused review of systems, as appropriate for the procedure
				or surgery
(e) Pre-procedure assessment and physical
				examination
(f) Assessment/impression and treatment plan
(4) For patients seen in
			 a hospital-based ambulatory clinic, the history and physical shall include at a
			 minimum:
(a) Chief complaint
(b) History of present illness
(c) Medications and allergies
(d) Problem-focused physical examination
(e) Assessment or impression
(f) Plan of care
(5) Deadlines and
			 sanctions.
(a) A history and physical examination must be performed by a
				member of the medical staff, his/her designee or other licensed health care
				professional, who is appropriately credentialed by the hospital, and be signed,
				timed and dated.
(b) Patients admitted to the hospital: If the
				history and physical is performed by the medical staff members designee
				or other licensed health care professional who is appropriately credentialed by
				the hospital, the history and physical must be countersigned by the responsible
				medical staff member.
(c) The complete history
				and physical examination shall be dictated, written or updated no later than
				twenty-four hours after admission for all inpatients.
(d) Admitted patients or
				patients undergoing a procedure or surgery, the history and physical
				examination may be performed or updated up to thirty days prior to admission or
				the procedure/ surgery or the visit. If completed before admission or the
				procedure/ surgery or patients initial visit, there must be a notation
				documenting an examination for any changes in the patients condition
				since the history and physical was completed. The updated examination must be
				completed and documented in the patients medical record within
				twenty-four hours after admission or before procedure/surgery, whichever occurs
				first. It must be performed by a member of the medical staff, his/her designee,
				or other licensed health care professional who is appropriately credentialed by
				the hospital, and be signed, timed and dated. In the event the history and
				physical update is performed by the medical staff members designee or
				other licensed health care professional who is appropriately credentialed by
				the hospital, it shall be countersigned, timed and dated by the responsible
				medical staff member.
(i) For
				  patients undergoing an outpatient procedure or surgery, regardless of whether
				  the treatment, procedure or surgery is high or low risk, a history and physical
				  examination must be performed by a member of the medical staff, his/her
				  designee, or other licensed health care professional who is appropriately
				  credentialed by the hospital and must be signed or countersigned when required,
				  timed and dated. 
(ii) If a
				  licensed health care professional is appropriately credentialed by the hospital
				  to perform a procedure or surgery independently, a history and physical
				  performed by the licensed health care professional prior to the procedure or
				  surgery is not required to be countersigned. 
(e) Hospital-based ambulatory clinic: If a
				history and physical examination is performed by a licensed health care
				professional who is appropriately credentialed by the hospital to see patients
				independently, the history and physical is not required to be countersigned.
				
(f) When the history and
				physical examination, including the results of indicated laboratory studies and
				x-rays, is not recorded in the medical record before the time stated for a
				procedure or surgery, the procedure or surgery cannot proceed until the
				history, and physical is signed or countersigned when required, by the
				responsible medical staff member, and indicated test results are entered into
				the medical record. In cases where such a delay would likely cause harm to the
				patient, this condition shall be entered into the medical record by the
				attending responsible medical staff member, his/her designee or other licensed
				health care professional, who is appropriately credentialed by the hospital,
				and the procedure or surgery may begin. When there is a disagreement concerning
				the urgency of the procedure, it shall be adjudicated by the medical director
				or the medical directors designee.
(g) Ambulatory patients
				must have a history and physical at the initial visit as outlined in paragraph
				(A)(4) of this rule.
(h) For psychology,
				psychiatric and substance abuse ambulatory sites, if no other acute or medical
				condition is present on the initial visit, a history and physical examination
				may be performed either:
(i) Within the past six
				  months prior to the initial visit,
(ii) At the initial
				  visit, or
(iii) Within thirty days
				  following the initial visit.