An admitting "history and physical" (H&P) document must be filed for all admitted patients. When adding a note to a patient's chart, "H&P" is one of the note types available for selection; it is not possible to sign a new note without a type selection. 

Encounter Documentation Norms and related Workflows are described in the Connect Care Manual. 

• Connect Care Manual on Required Documentation for Inpatient Encounters

Admission History and Physical

This metric measures the timeliness of history and physical exam documentation when it is first signed off by the appropriate provider (e.g., acute care attending physician, but could be a resident). The following note types count toward the metric: H&P; H&P (View-Only); & Interval H&P Note. 

The attributing department is the department where the patient was first an inpatient 

History and Physical Timeliness

Description

• Displays the proportion of hospital inpatient encounters where history and physical exams were documented within 24 hours, 48 hours, and 72 hours of admission. 

Denominator

• Number of Patient Encounters where:

  • Patient Class (I EPT 10110) = Inpatient [101] AND 

  • ADT Patient Status (I EPT 10115) = Admission [2] OR Discharged [3] AND 

  • Date and Time When First Inpatient (I EPT 10290 and I EPT 10291) exists

Numerator

• Number of Patient Encounters from denominator where:

  • Note (HNO) exists, linked via I EPT 20330 AND 

  • Note is not deleted (I HNO 34150 Delete Instant is empty) AND

  • Note is not created via a scan (I HNO 1029 = No OR is empty) AND

  • Note Type (I HNO 34033) = H&P [4] OR H&P (View-Only) [26] OR Interval H&P Note [27]) AND 

  • Note Status (I HNO 17100) = Signed [2] OR Cosign Needed [9] AND 

  • Action Taken on Note (I HNO 34040) = Sign [2] AND 

  • Action Taken Instant (I HNO 34052) MINUS Date and Time When First Inpatient (I EPT 10290 and 10291) IS LESS THAN OR EQUAL TO 24/48/72 hours 

Calculation

• Numerator DIVIDED INTO Denominator expressed as PERCENTAGE rounded up to nearest integer percentage point

Summary Levels

• Hospital Specialty Service: EPT 18886 - (e.g., General Internal Medicine [106])

• Department*: EPT 18880 - inpatient unit/ward (e.g., EDM UAH WMC 5D4 GIM [101094229])

• Revenue Location: EPT 18883 - (e.g., EDM WMC University of Alberta Hospital [101094])

• Service Area: EPT 18881 - (eg. AHS CONNECT CARE SERVICE AREA)

*Department is defined as: 

First admitting unit (I ADT 50) EXCLUDING:  

ADT Unit Type (I DEP 7050) = Emergency Dept [1]

OR  

OR Unit Type (I DEP 6100) = NOT NULL (Excludes ORs)

Analytics Definition

• Crib-Sheet: Admission History & Physical Timeliness

History & Physical Timeliness Metric

This metric provides information on if the H&P was completed on time but cannot provide additional context on why delays may have occurred.

This metric does not measure documentation quality or accuracy of the documented H&P.

Radar Dashboards

Reporting Workbench

Slicer-Dicer