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Based on record review and interview, the hospital failed to ensure medical record entries of 3 of 10 patient medical records (Patient #1,#4, and #9) were reviewed completed, signed, dated and timed.

Findings include:
1.) Patient #1 had a left carotid endarterectomy on 12/11/2018. History and Physical (H&P) was dated 11/21/2018. The update for the History and Physical that was stamped on the History and Physical states; "Patient assessed. History and Physical reviewed. No changes indicated, Signature/Date and Time." The History and Physical was initialed by the physician, however there was no date and time on the H&P to indicate when the update on the H&P was reviewed and declared no changes.

2) Patient #4 had a left carotid endarterectomy on 12/11/2018. The H&P was done on 12/5/2018. The H&P had a stamp on the form that stated "Patient assessed. History and Physical reviewed. No changes indicated." Signature/Date/Time. The H&P was initialed by the physician but there was no date or time of the update.

3 ) Patient #9 had a right carotid endarterectomy on 1/14/2019. The H&P was done on 1/2/2019. The H&P had a stamp on the History and Physical that stated "Patient assessed. History and Physical reviewed. No changes indicated." Signature/Date/Time. The physician initialed next to the stamp however he did not date or time his signature.


The charts were reviewed with Personnel #4 on 2/26/2019 at approximately 2:30 PM and he confirmed that the History and Physical updates were not completed with a time and date of the signature as the form indicated.