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Message from the CMO
Time, Date, and Sign
History and Physical
Immediate Post Procedure Note

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Message from the CMO


Immediate Post Procedure Note


Documentation Requirements

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 July 2012



This newsletter will review various issues that were found with the recent Joint Commission Survey at CHRISTUS Santa Rosa.  Please read the following sections as they apply to your practice.

Message from the CMO

Jim Martin, MD

While regulatory agency inspections create a time of tension, they serve as a good external audit of whether we are really doing what we say we do.  Our recent Joint Commission survey identified several areas where we as physicians have not consistently followed our own policies. 

You should be very familiar already with the following documentation requirements, and yet we continue to find areas of non- compliance:

  • Sign, date, and time each entry in the medical record.
  • Complete or update history and physicals within 24 hours.
  • Dictate operative reports within 24 hours.
  • Complete immediate post procedure note prior to moving the patient to the next level of care, including estimated blood loss and specimens removed.
  • Always utilize the CSR Restraint Order Form when ordering restraints, completing all of the required fields.
  • Complete the required fields in the anesthesia record, including immediate pre-induction vital signs and pain evaluation.
  • Sign, date and time telephone orders within 48 hours.

The non -compliance with our own medical staff policies is a very serious finding, and we must hold ourselves accountable and correct it now.


Medical Records (HIM) and nursing staff are monitoring active patient charts for compliance to the above issues. Non compliance by physicians may result in corrective action taken by medical staff leadership and may include restriction or suspension of privileges. At the same time, active patient charts are being randomly audited to validate the success of this monitoring program. Continued violations by physicians may result in corrective action.


 Read on


Sign, Date AND Time Each Entry

Sign, date and time each entry in the medical record when the documentation occurs. This includes History and Physical, Progress Notes, Physician Orders, Consents, Operative Notes.

  • Telephone orders must be signed, dated and timed within 48 hours.
  • Verbal orders are limited to EMERGENT, URGENT OR PROCEDURAL situations.

Preadmission or telephone orders, including medication orders, may be issued by or to appropriately licensed staff.   All preadmission or telephone orders shall be countersigned, dated and timed by the practitioner who issued the order, or an appropriately privileged and credentialed designee or assigned House Staff Physician who is involved in the care of the patient within forty-eight (48) hours.

H&P Revisited

Physician charting 

H&P must be completed and documented within 24 hours following admission of the patient, but prior to surgery or a procedure requiring anesthesia services (including moderate sedation).


H&P exams performed within 30 days prior to admission may be used if the following requirements are met:

  • Physician writes an update note which is written on or attached to the H&P;
  • The words "re-examined the patient" must be present; and
  •  The H&P and any updates/assessments must be included in the medical record within 24 hrs of admission, but prior to surgery or other procedures whichever comes first.

H&P performed more than 30 days prior to admission, outpatient, observation, or outpatient surgery does not comply with timeliness requirements and a new H&P must be performed.

H&P Required Components:
  • Chief Compliant
  • Details of Present Illness
  • Relevant Past Social and Family History
  • Physical Examination
  • Statement on conclusions

Immediate Post Procedure Note


There is a common misperception that if a physician dictates an operative note immediately following surgery then a hand-written immediate post-operative note is not needed.  However, a post-op progress note must be available in the medical record prior to the patient leaving the operating room and before the patient moves to the next level of care. The post-op progress note has been updated and is available in each of our operating rooms to assist in compliance with this requirement.


The required elements of the post-op progress note are:  

  • Name of Surgeon and Assistant(s)
  • Pre-operative Diagnosis
  • Post-operative Diagnosis
  • Name of procedure(s) performed
  • Findings of the procedure
  • Estimated blood loss
  • Specimens removed
  • Signed by physicain
  • Date and time recorded - Very important as it confirms that the note was recorded prior to moving the patient to the next level of care
    Click here to review the Immediate Post-Op Progress Note form. 



The CHRISTUS Health policy on the standardized use of restraints/seclusion requires that the licensed independent practitioner document the need for continued use of restraint on a daily basis.  During our most recent survey, no documentation was found in several instances. 


This requirement can be easily met by checking the box on the physician's order that indicates that the observation and assessment have been completed and the continued use of restraint is appropriate.  When accompanied by your signature, time and date, this constitutes a complete order for continued restraint.

Click here for a summary of additional documentation requirements.

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Have questions regarding this newsletter? Please contact:

Jann Harrison, RN, MSN, Director of Medical Education

CHRISTUS Santa Rosa Health System