Question

If a patient is an inpatient what is needed with regard to the history and physical

a) documentation in the progress/consult note with any changes in the patient's condition
b) a new H&P
c) electronic attestation
d) no action is needed

Answer 1

Documentation for an inpatient should include notes on any changes in the patient's condition within progress or consult notes, and sometimes a new H&P may be needed. Policies regarding health records must consider cost efficiency, quality of life, and privacy protection.

Step-by-step explanation:

If a patient is an inpatient and there is a need to document the history and physical (H&P), several actions might be required. Generally, the progress or consult note should include documentation of any changes in the patient's condition. This might include updates since the last H&P, significant new findings, and the patient's current status. In some cases, depending on the time elapsed since admission or if there has been a significant change in the patient's condition, a new H&P may be required. Additionally, electronic attestation might be necessary to confirm that the documentation is accurate and complete.

Ensuring accurate health records is a concern in medical practice. When developing policies that balance the costs of treatments and diagnoses, patient quality of life, and risks to individual privacy, several questions must be addressed, such as:

1. 
   
3. How can the policy ensure the minimization of unnecessary costs without compromising the quality of patient care?
4. 
   
6. What measures are in place to maintain or improve patient quality of life while respecting their choices and privacy?
7. 
   
9. How will patient data be protected to minimize risks to individual privacy?