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From HIM: Vital signs ARE an H&P documentation rule

By Gena Inches, HIM manager

To address recent questions, HIM has clarified that vital signs must be documented. The Salem Health Medical Staff rules align with CMS and Joint Commission H&P documentation requirements.

To customize your template to add required H&P elements, place a request with the Solution Center at 503-814-4357.

H&P requirements listed in SH Medical Staff R&R (pages 11-12):  

  • Chief complaint
  • Details of present illness (reason for hospitalization)
  • Presence of significant allergies or documentation of none
  • Current medications which are pertinent to the reason for admission or procedure
  • Physical examination, including vital signs
  • Impression, differential diagnosis, conclusion
  • Treatment
  • Plan

H&P update requirements:

  • H&P reviewed
  • Patient examined
  • Document if there are no changes or changes noted

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