Joint Commission Requirements for History and Physical

The Joint Commission provides accredited status to health-care organizations that choose to comply with its standards. The commission has several hundred standards designed to provide safe, high-quality patient care.

Documentation

• The Joint Commission has many standards on documentation requirements, with the belief that proper documentation can minimize and even prevent medical errors and patient harm.

Requirements

• The Joint Commission's "Record of Care Treatment and Services" standards include requirements on documenting patient history and physical examinations.

Time Frame

• Per Joint Commission requirement RC 01.03.01, a patient's medical history and physical examinations, with updates, is recorded in the medical record within 24 hours of admission, and before any procedure requiring anesthesia.

Features

• The Joint Commission does not indicate what needs to be in the history and physical. It is up to the individual organization to determine the content and to follow its own established guidelines. The commission does state that the data should contain the information to provide the necessary care for the patient.

Warning

• During an unannounced survey, the Joint Commission may conduct random chart reviews to assess an organization's compliance with this requirement.