St. Mark's Hospital - July 01, 2017

Clinically appropriate documentation prior to a procedure is a patient safety issue.

Please remember that a clinically appropriate H&P must be present in the medical record prior to any procedure, with the only exception of a life-threatening emergency. In a life-threatening emergency, the H&P must be completed as soon as the emergency condition has been stabilized.

If a clinically-appropriate H&P is not present and visible in the medical record, prior to a procedure, the procedure is to be delayed until the H&P is complete and visible. In the situation in which an H&P is missing, the operating surgeon should request his/her office to immediately transmit the H&P, or he/she may enter and H&P in Epic or write an H&P on a paper form.

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