HospitalInspections.org

Based on review of medical records 7 of 10 emergency medical records were incomplete The records did not contain intake, output, and discharge documentation.

Findings were:
Review of policy Standards of Practice, Emergency Department Policy #103.1 page 2 of 3, K. Documentation should reflect a complete account of the care and treatment received by the patient during his or her ED stay. X. Individualized discharge planning and teaching prior to dismissal should be implemented. Documentation should include patient ' s understanding of instructions, copy of instructions, given, name of physician or clinic the patient should follow-up with, condition upon dismissal, mode of dismissal and time of dismissal.

6 of 10 emergency medical records reviewed did not have completed intake and outputs. Patient # 2,3,4,7,8,and 9.
7 of 10 emergency medical records reviewed did not have complete discharge information. Patient # 2,3,4,6,7,8,and 10.

The findings were confirmed in an interview with the staff #2 at the facility on the afternoon of 1/30/17.