H&P Requirements for OB Patients

Hi,

What is your History and Physical requirement for patients who deliver at your hospital? We require a short form H&P and the pre-natal notes from the hospital. If the patient converts from vaginal delivery to c-section, we require a dictated H&P even if a short form has been done. I am wondering if all this is necessary. What do you require? How about observation patients?

Thanks for your help.

Kathy

Katherine A. Hopkins, RHIA, RN
Health Information Manager
Ridgecrest Regional Hospital
1081 N. China Lake Blvd.
Ridgecrest, CA 93555
(760) 499-3670

Comments

  • edited May 2016
    We do not have OB at our facility.



    Suzanne LeMaire, RHIT

    HIMS Leader

    Scheurer Hospital

    170 North Caseville Road

    Pigeon, MI 48755-9781

    phone: 989.453-5205

    fax: 989-453-4455

    email: lemaires@scheurer.org
  • edited May 2016
    For vaginal deliveries, the prenatal notes from the physician is the H&P; a full H&P is required for a c-section. An H&P is only required for observation patients that have a procedure requiring an H&P.

    Sheila Schultz
    Director of HIM
    Wheeling Hospital
    One Medical Park
    Wheeling WV 26003
    304-243-3695
    Fax 304-243-8599
    sschultz@wheelinghospital.org
  • edited May 2016
    We recently reviewed this at our hospital. As long as there is documentation of the prenatal H & P and subsequent visit notes, we just require an updated note within 24 hours of admission or prior to the surgery ( c-section)

    Betty

    Elizabeth MacInnes, MHA, RHIA, CPHRM
    Vice, President, Quality
    Portage Health
    Hancock, MI 49930
    906-483-1504 work
    emacinnes@portagehealth.org
  • edited May 2016
    OB/GYN normal delivery prenatal notes from the doctor's office is the H&P, if a C-section then it does require a full H&P. Observation or Inpatient here less than 24 hours short form H&P, greater than 24 hours full H&P. Hope that helps!


    Thank you,

    Cindi Majewski
    Director of Medical Records
    ________________________________
    United Regional
    1600 Eleventh Street
    Wichita Falls, Texas 76301
    Voice:(940) 764-3129
    Fax: (940) 764-3355
    cmajewski@unitedregional.org
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