CMS History and Physical Requirements for Hospitals

Hospitals that bill Medicare or Medicaid must document a History and Physical examination for every patient who is admitted or registered, and the CMS history and physical requirements set two deadlines: the H&P can be completed no more than 30 days before admission or registration, or it must be completed within 24 hours after. Either way, it has to be in the medical record before any surgery or procedure requiring anesthesia. The rules sit in 42 CFR 482.22 (medical staff) and 42 CFR 482.24 (medical record services), and they are Conditions of Participation, meaning a pattern of failures can cost a hospital its provider agreement.¹

The 30-Day and 24-Hour Timing Rules

A complete H&P is timely if it was performed no more than 30 days before admission or registration, or if it is completed within 24 hours after admission or registration.² Regardless of which window applies, the H&P must be in the record before any surgery or anesthesia procedure begins.³

The regulation says “admission or registration,” and that phrasing matters. The requirement reaches beyond inpatients to patients registered for outpatient procedures, including emergency department patients who are then admitted or taken to surgery.³

The Required Update

An H&P performed within the 30 days before admission cannot simply be dropped into the chart on its own. An updated examination must be documented within 24 hours after admission or registration, and before any surgery or anesthesia, noting any changes in the patient’s condition since the earlier exam.² If nothing has changed, the update should say so on the record rather than leave the question open. The same categories of practitioners qualified to perform the original H&P may perform the update.

Who Can Perform and Sign the H&P

Only three categories of clinicians can complete and document the H&P: a physician as defined by the Social Security Act, an oral and maxillofacial surgeon, or another qualified licensed individual permitted by both state law and hospital policy.² CMS interpretive guidance treats nurse practitioners and physician assistants as falling in that third category when state scope of practice and hospital privileges allow it.⁴

More than one practitioner can contribute to a single H&P. When the work is split, the practitioner who authenticates the final document is responsible for its contents. One additional constraint applies when a non-physician admits a Medicare or Medicaid patient: that patient must still be under the care of an MD or DO.⁴

What the H&P Must Contain

The regulation calls for a “medical history and physical examination” without itemizing every clinical element, but CMS expects enough detail to justify the admission, support the diagnosis, and describe the patient’s condition.³ In practice, that means two documented pieces.

The history covers the chief complaint, a chronological account of the present illness, a review of systems, and past medical, family, and social history including prior illnesses, surgeries, medications, allergies, and relevant lifestyle factors.⁵ The physical exam documents objective findings, starting with vital signs and general appearance and then examining the systems relevant to the presenting problem. Depth should scale with clinical complexity: a routine outpatient procedure and a critically ill ICU admission are not documented at the same level.

Authentication and Retention

Every entry in the medical record, including the H&P, must be legible, complete, dated, timed, and authenticated by the person responsible for the service, in written or electronic form.³ Electronic signature systems must include protections against modification, and the provider whose name is on the signature accepts responsibility for the entry’s authenticity. When a scribe or AI tool drafts a note, the author still has to personally sign it.⁶

Federal rules require hospitals to keep medical records for at least five years.³ Many states set longer periods; follow whichever is stricter.

The Outpatient Surgery Exception

A hospital’s medical staff may adopt a policy allowing a more limited pre-procedure assessment, in place of the full H&P and its 24-hour update, for certain outpatient surgical or procedural services under 42 CFR 482.22(c)(5)(iii).² The exception is optional; a hospital can still require the full H&P for everyone.

If a hospital does adopt this policy, the criteria have to reflect:

Patient-specific factors, including age, diagnoses, comorbidities, and the type and number of procedures scheduled
The level of anesthesia required
Nationally recognized guidelines and standards of practice for assessing the relevant patient types before the relevant procedures
Applicable state and local health and safety requirements

The limited assessment still has to be done after registration and before surgery or anesthesia, and by a practitioner who meets the same qualifications required for a full H&P.² Inpatient admissions are outside the exception and always require the full H&P.

The Pre-Anesthesia Evaluation Is Separate

The H&P does not stand in for the pre-anesthesia evaluation. Under 42 CFR 482.52, an individual qualified to administer anesthesia must complete and document a preanesthesia evaluation within 48 hours before any procedure requiring anesthesia services.⁷ A surgical patient needs both documents in the record: a timely H&P and, within 48 hours of the procedure, the preanesthesia evaluation. Missing either one is a citable deficiency.

Teaching Hospitals

Where residents or students perform part of the work, extra rules apply. Medical students may make entries in the record, but a teaching physician has to verify all student documentation of history, physical exam findings, and medical decision-making.⁸ For separately billable E/M services, the teaching physician must personally perform or re-perform the physical exam and decision-making components; students cannot document the review of systems or the past, family, and social history for those billable services.

When a resident performs the H&P, the teaching physician documents involvement through an attestation showing presence, participation in the key portions, and agreement with the resident’s findings and plan. If the teaching physician disagrees with any finding, the attestation notes the difference and records the revised plan. For late-night admissions, the teaching physician may reference the resident’s note without re-documenting, provided the patient’s condition has not changed and the teaching physician agrees with what the resident wrote.⁸

Psychiatric Hospitals

Psychiatric hospitals meet all the standard H&P requirements plus the additional ones in 42 CFR 482.61. The record must document legal status, a provisional or admitting diagnosis covering both psychiatric and concurrent medical conditions, reasons for admission as stated by the patient and by others involved, social service interviews with the patient and family, and a complete neurological examination at the time of admission when clinically indicated.⁹

Each patient also needs a separate psychiatric evaluation within 60 hours of admission, covering medical history, mental status, onset of illness and circumstances leading to admission, attitudes and behavior, estimates of intellectual and memory functioning and orientation, and an inventory of the patient’s assets. The 60-hour window is tighter than many facilities plan for, and missing it is a recurring survey finding.

What Happens When Hospitals Fall Short

Surveyors track H&P failures under specific deficiency tags in the medical record services standard at 42 CFR 482.24(c)(4).⁴ The common ones include A-0458 (no H&P within the required timeframe), A-0461 (no update when the original H&P was completed within the 30 days before admission), A-0462 (missing patient assessment under a hospital’s outpatient exception policy), and A-0358 (medical staff bylaws that omit the H&P requirement).

When a hospital fails to meet Conditions of Participation, CMS can terminate the provider agreement under 42 CFR 489.53(a)(3).¹⁰ Termination means the loss of Medicare and Medicaid billing, and reenrollment can be barred anywhere from one to ten years depending on how serious the violations were. A single missed H&P is unlikely to trigger termination, but a pattern across charts reads as a systemic problem, and surveyors treat it that way. Most hospitals get a plan-of-correction opportunity first, and the corrective action has to reach root causes rather than fix a handful of individual records.

1
eCFR. 42 CFR Part 482 – Conditions of Participation for Hospitals
2
eCFR. 42 CFR 482.22 – Condition of Participation: Medical Staff
3
eCFR. 42 CFR 482.24 – Condition of Participation: Medical Record Services
4
Centers for Medicare & Medicaid Services. State Operations Manual Appendix A – Survey Protocol, Regulations and Interpretive Guidelines for Hospitals
5
Centers for Medicare & Medicaid Services. 1997 Documentation Guidelines for Evaluation and Management Services
6
Centers for Medicare & Medicaid Services. Complying with Medicare Signature Requirements
7
eCFR. 42 CFR 482.52 – Condition of Participation: Anesthesia Services
8
Centers for Medicare & Medicaid Services. Guidelines for Teaching Physicians, Interns and Residents
9
eCFR. 42 CFR 482.61 – Condition of Participation: Special Medical Record Requirements for Psychiatric Hospitals
10
eCFR. 42 CFR 489.53 – Termination by CMS