The Joint Commission is scheduled to survey Sharp
Grossmont Hospital very soon. In our efforts
towards "continuous readiness," a two-day
mock survey was conducted this week. A
potential
area of non-compliance was reported. The
medical
staff must
address this issue regarding timely H&Ps
and required updates to H&Ps.
To be very
clear, even if a physician did an H&P in
his/her office just hours before the patient was
admitted to the hospital, an update must be done
within 24 hours
after inpatient admission or prior to surgery (whichever
comes
first). No patient will be taken to
the surgical or procedural venue until the update has
been completed.
As Chief of
Staff, I
have assumed responsibility for assuring
that we meet the JC standards. Therefore, I have
taken ownership and
intend to assure that our medical staff is in
compliance. All failures to meet this requirement will
be brought to my attention.
This message is sent not as a
reminder, but as a
directive, that
this requirement must
be
met
by all members of our medical staff.
"For a medical history and physical examination that
was completed within 30 days prior to inpatient
admission, an update documenting any changes in
the patient's condition is completed within 24 hours
after inpatient admission or prior to surgery, whichever
comes first." (Joint Commission Standard
PC.01.02.03 and MS.03.01.01 EP 8 and RC.02.01.03
EP 3)
