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SAINT FRANCIS MEDICAL CENTER
MEDICAL RECORD SERVICES
Tag No.: A0450
Based on document review and staff interview, it was determined in 1 of 10 (Pt #1) clinical records, the Hospital failed to ensure all entries in the medical record were accurate. This has the potential to affect all patients receiving care at the Hospital.
Findings include:
1. The Hospital policy titled, "Health Care Documentation" (revised 12/6/16) was reviewed on 3/22/17 at approximately 10:00 AM. The policy indicated the purpose of the policy was, "To provide accurate and timely documentation in patients' health records to facilitate best quality services and continuity of care."
2. The clinical record of Pt #1 was reviewed on 3/20/17 at approximately 11:00 AM. The clinical record contained the following discrepancies:
a. A. 2 view chest X-ray on 10/7/16 at 7:55 AM identified a "right PICC (Peripherally inserted central catheter) line. Impression: The distal end of the right PICC line remains looped in the base of the neck, likely the right internal jugular."
b. A Emergency Room timeline for Pt #1 was reviewed on 3/21/17 at approximately 4:00 PM. The timeline on 10/7/16 indicated Pt #1 entered the emergency department at 7:09 AM and was discharged from the emergency room at 3:50 PM. Pt #1 did not leave the emergency room. The time line indicated at 1:29 PM, MD #1 was "here to remove infected port."
c. The "General Surgery Consultation Note" dated 10/7/16 at 2:05 PM by MD #1 indicated the "port would be removed at bedside".
d. The "Procedure Note" dated 10/7/16 at 2:10 PM by the surgeon (MD #1) indicated :
"Removal of med-port; the patient was brought to the Operating Room; and a standard time out was performed."
e. The Operating Room Log for 10/7/2016 was reviewed on 3/22/17 at 4:00 PM. Pt #1 was not listed as an Operating Room patient.
3. An interview was conducted on 3/23/17 at approximately 2:30 PM with the Accreditation Officer (E #1). E #1 stated "The documentation does not clearly state what type of device the patient had or what department the device was surgically removed in. The documentation contradicts itself."