Review of H&P and

Consultations
A HIT Practicum Project by Ginger West
University of Cincinnati Clermont

Objectives

Learn about HIT Practicum Projects

Identify requirements for an HIT Practicum Project

Recognize the H&P (History & Physical)

Recognize a Physician Consultation

Learn the process of a review of an H&P

Learn the process of a review of a Physician Consultation

Identify key items needed for reviews

Recognize the purpose and end product of a review

HIT Practicum Project

Exposure

to a health information environment

Provided

hands on experience

Requirements

may include signed forms for the project,

signed HIPAA forms, and availability during the week
days

Requirements for a HIT Practicum Project

Authorization
Goal

Statement

Project

Scope

Deliverables

Resources
Risks
Task

Outline

Timeline

Authorization
Meet

with site supervisor

Practicum
Fill

Project is decided

out an authorization form

Submit

signed authorization form for approval

Project Goal Statement

Verification or an audit that the History and Physicals were done

within 24 hours and included all pertinent information

Verification or an audit that any Consultations were done within

72 hours and included all pertinent information

Final results are provided to Select Specialty Hospital; ensures

documentation processes are working properly

Project Scope
Location
Current

Select Specialty Hospital

patients at Select Specialty Hospital

Required

to review ten medical records

Project Deliverables

Verification of individual patient medical records H&P within 24

hours including all pertinent information in table form

Verification of individual patient medical records Consultation's

within 72 hours including any pertinent information in table form

Summary report in spreadsheet format showing totals for H&P

and Consultation results

Practicum project portfolio & Power Point presentation of the

final project results

Resources

Facility Site Director- Nancy Collins

Current medical records of residents

Microsoft Excel

Microsoft Word

Physician list

Jud Clemens- Site Health Information/ Credentialing Manager

Professor of the Practicum class

Portfolio components

Project Risks

Availability of the medical records

Possible incomplete data of the H&P and Consultations within

the record

Availability of physician to administer TB test

Time needed to complete other classwork, study for certification,

and graduation preparations

Support from medical facility staff and availability to establish

effective communications

Project Task Outline

Task

Start

Finish

Duration

Determine project objectives, scope, and other details with Site

Supervisor

March 21

March 21

1 day

Create individual forms for medical records results in Excel and

print

March 22

March 22

2 Hours

Create Excel formula to compute results for summary

March 22

March 22

1 Hour

Acquire a TB test

March 28

March 31

4 Days

Create project authorization form and gather necessary forms

(Confidentiality Statement)

March 21

March 24

4 Days

Review medical records for H&P and Consultation information

March 21

April 14

6 Days

Create Practicum Project forms: goal, scope, deliverables, etc.

April 15

April 18

4 Days

Enter data and compile summary

April 12

April 21

10 Days

Assemble the PPE portfolio & Power Point

April 16

April 21

6 Days

Deliver completed PPE portfolio

April 25

April 25

1 Hour

Project Timeline
Description of Work

Timeline

Determine project goal, scope, and other details with Site

Supervisor

March 21

Review H&P and Consultations in medical records

March 21-April 14

Create project authorization form and assemble other required

forms (confidentiality/ signed physician forms)

March 21-March 24

Design and create spreadsheets to document results

March 22-March 22

Enter data and compile summary

April 12-April 21

Assemble the PPE portfolio & Power Point

April 16-April 21

Deliver completed PPE portfolio

April 25

The H&P (History & Physical)

The History & Physical must be completed within 24 hours of the admission

The H&P includes:

Chief Complaint or Diagnosis

Present Illness Summary

Past Medical History

Family History

Social History

Medications

Physical Exam or Assessment

Labs

Plan of Care

The Consultation
Must

be done within 72 hours of the request for

Consultation

Reason

for the Consultation

Patient Assessment
Patient

Plan

Includes

many of the items in a H&P

Review of an H&P

Requires a list of credentialed physicians for the medical facility

Begin with identifying the patients name, medical record number, and
admitting date

Find the H&P tab in the medical record and locate the History & Physical

Compare the completion date and time of the H&P to the admitting date

Verify inclusion of pertinent information (Diagnosis, Present Illness, and

others)

Document the results of review

Document any questions for Nancy

Review of Physician Consultations

Consultation forms are to be located in the H&P section

Request for a physician consultation may be located in the Orders

section on line 21 of the Admission Order

Request for consultation includes physicians name and area of medicine

Consultation may be performed by someone other than requested

physician

Consultations may be placed in other location, Physician Progress

Notes

Compare Consultation date with Consultation request date (72 hours)

Review of Physicians Consultation

Continued

Verify reason for consult, patient assessment, and patient plan

Document review results

Document any questions for Nancy

Not all medical records include a request for a physician

consultation

Occasionally a recent physician consultation has been completed

prior to admission

Results of the Review

10 out of 10 medical records included a History and Physical

completed within 24 hours

8 out of 10 medical records included all pertinent information

2 out of 10 medical records did not include labs

9 out 9 Consultations requested were completed within 72 hours

2 medical record did not include a request for a consultation

1 medical record included two requests for consultations

Finalizing the Review of History & Physicals

and Physician Consultation's

Results of the review were entered into Excel, printed, and

distributed to Site Supervisor

The Project Goal to complete a current review (audit) of medical

records regarding H&Ps and Physician Consultations was
accomplished

The Project provided Select Specialty Hospital with data to

ensure compliance in medical record documentation according to
regulations