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According to TJC standards, a complete H&P examination must be documented no more than 30 days before or 24 hours after admission or registration, but prior to surgery or a procedure requiring anesthesia services. The H&P must be placed in the patient’s medical record within 24 hours after admission or registration, but prior to surgery or a procedure requiring anesthesia services. The H&P includes information about the patient’s medical, surgical, family, and social history, review of systems,
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