Certified Inpatient Coding (CIC) Practice Exam

When does The Joint Commission require a history and physical to be available for review in a patient's medical record prior to surgery?

1. No more than 30 days prior to surgery, or within 24 hours after admission, but prior to the surgery.

2. No more than 30 days after surgery, or within 24 hours after admission, but prior to the surgery.

3. Within 7 days after the surgery.

4. Within 30 days after the surgery.

The correct answer is: No more than 30 days prior to surgery, or within 24 hours after admission, but prior to the surgery.

The correct answer indicates that The Joint Commission requires a history and physical examination to be available for review in a patient's medical record no more than 30 days prior to surgery or within 24 hours after admission, but prior to the surgery itself. This requirement is crucial for ensuring patient safety and providing a comprehensive understanding of a patient’s medical history and current health status before they undergo any surgical procedure. Having this documentation completed within this timeframe allows the surgical team to assess any potential risks and make informed decisions regarding the surgical approach, anesthesia considerations, and post-operative care plans. It also ensures compliance with regulatory standards, which are designed to promote the safety and quality of care in healthcare settings. The time-bound nature of needing the history and physical examination before the surgery underscores the importance of timely documentation and review processes in acute care settings. This standard helps to prevent any delays or oversights that could impact patient outcomes during surgery.