1
Health records documentation and storage
Western Governors University
C803 Task 4
2
Health records documentation and storage
A1. TJC standards and Utah state standards
A history and physical (H&P) is the most important first step in providing accurate and
excellent care to patients. This is because it diagnoses the patient, paves the treatment path and
ongoing care. The Joint Commission (TJC) has created national standards. However, states, such
as Utah, may also have their own standards. This presentation will evaluate standards required by
the TJC and the state of Utah.
A2. Similarities between TJC standards versus Utah state standards
The H&P standards that were compared include: content, time frame, validation, and
consents (Cornell Law School, 2017). The similarities between TJC and Utah state were
identical. The first similarity is content requirements; Utah requires a detailed patient history and
physical to be done. The H&P must be done within the first 24 hours of a patient being admitted.
Validation of the H&P needs to be signed off by a licensed medical provider. Utah requires
documentation to be done during the H&P process (Cornell Law School, 2017).
, In comparison, TJC also requires a detailed patient history and physical to be done (The
Joint Commission, 2020). The H&P must be done within the first 24 hours of a patient being
admitted. Validation of the H&P needs to be signed off by a licensed medical provider. TJC
requires documentation to be done during the H&P process (The Joint Commission, 2020).
A3. Differences between TJC standards versus Utah state standards
The H&P differences that were compared include: signature, updates, and documentation
(Cornell Law School, 2017). Regarding the Utah state signature for a completed H&P, this can
be done by the provider who performed the assessment, and also a nurse practitioner or a
supervising physician. The H&P updates do note specifically mention updating the H&P, only
Health records documentation and storage
Western Governors University
C803 Task 4
2
Health records documentation and storage
A1. TJC standards and Utah state standards
A history and physical (H&P) is the most important first step in providing accurate and
excellent care to patients. This is because it diagnoses the patient, paves the treatment path and
ongoing care. The Joint Commission (TJC) has created national standards. However, states, such
as Utah, may also have their own standards. This presentation will evaluate standards required by
the TJC and the state of Utah.
A2. Similarities between TJC standards versus Utah state standards
The H&P standards that were compared include: content, time frame, validation, and
consents (Cornell Law School, 2017). The similarities between TJC and Utah state were
identical. The first similarity is content requirements; Utah requires a detailed patient history and
physical to be done. The H&P must be done within the first 24 hours of a patient being admitted.
Validation of the H&P needs to be signed off by a licensed medical provider. Utah requires
documentation to be done during the H&P process (Cornell Law School, 2017).
, In comparison, TJC also requires a detailed patient history and physical to be done (The
Joint Commission, 2020). The H&P must be done within the first 24 hours of a patient being
admitted. Validation of the H&P needs to be signed off by a licensed medical provider. TJC
requires documentation to be done during the H&P process (The Joint Commission, 2020).
A3. Differences between TJC standards versus Utah state standards
The H&P differences that were compared include: signature, updates, and documentation
(Cornell Law School, 2017). Regarding the Utah state signature for a completed H&P, this can
be done by the provider who performed the assessment, and also a nurse practitioner or a
supervising physician. The H&P updates do note specifically mention updating the H&P, only
