Guest Post: Documentation tips for a stellar H&P

By Mary Solomon, BSN, RN, CCM, CCDS

Have you ever read a history and physical (H&P) report and wondered why the patient was admitted? Have you ever wondered which diagnoses were resolved prior to admission?

If you are a CDI specialist or coder you’ve probably struggled with these questions many times. At our hospitals, the CDI and coding staff decided that physician education was the best approach to deal with the challenge of incomplete H&P documentation.

The H&P is an essential document that provides the framework to establish the principle diagnosis and all co-morbid conditions. The data from the H&P assists in determining the DRG, length of stay, severity of illness and risk of mortality.  Components of the H&P include the chief complaint and the primary reason for admission to the hospital. Without these components, it is difficult to determine the principle diagnosis and the appropriate DRG assignment.

Once we identified the problem of incomplete H&P documentation, we developed a plan to address it. We worked collaboratively on a tip sheet to help during the dictation process. We used a three-pronged approach to our educational campaign:

1. The tip sheet was posted next to the dictation phone on the nursing unit.
2. Individual copies of the tip sheet were given to each admitting physician.
3. An article including the tip sheet was published in the quarterly HIM Newsletter.

The tip sheet was written in bullet format for ease of reading. The following is a summary of the documentation tips:

• Components of the H&P include:
  
  • reason for admission
  • chief complaint
  • details of current illness
  • relevant medical, social and family history
  • allergies
  • review of systems
  • physical examination
  • conclusions or impressions
  • treatment plan

• When a discharge/transfer summary is used in lieu of an H&P, the document must include all of the elements of an H&P.
• In order to capture any changes since dictation of the discharge/transfer summary, a form will be placed in the chart requesting an interval note. The most important documentation elements to include on the form are the diagnoses for admission and any changes that have occurred.
• For accuracy of coding, list all current diagnoses. If a diagnosis is listed but is no longer present or no longer being treated, document that it was resolved prior to admission. Include documentation of the etiology, severity and acuity of the diagnosis(es), if known.
• Use care when documenting that the patient is status-post with regards to a chronic illness. For example, patients with chronic diseases such as hypertension or hypothyroidism generally still have these conditions, but they are controlled with medication.
•  If a medication or treatment is ordered for a specific diagnosis, that diagnosis should be documented in the H&P.

Since the tip sheet was posted a month ago, we noticed some improvements in the quality of documentation. The H&Ps were less likely to have missing elements. The documentation was clearer regarding present on admission vs. resolved prior to admission. Also, the reason for admission was documented more consistently. However, the sample size was not large enough to draw any significant conclusions. We plan to track the data on H&P documentation over the next several months to determine the effectiveness of our educational approach.

Editor’s Note: Solomon, at the time of this article's original release, was a CDI specialist at Tahoe Pacific Hospitals in Reno, Nevada. She received her BSN from San Francisco State University. She has more than 35 years of experience as an RN in med-surg, intensive care and home health nursing. She worked as a case manager in acute care, worker’s compensation and community-based settings. She started her CDI career in 2011.