HospitalInspections.org

Based on review of facility documents, review of medical records (MR), and staff interviews (EMP), it was determined that the facility failed to maintain an effective medical record service that has administrative responsibility for medical records by failing to maintain a medical record for each outpatient, including ensuring that each record is promptly completed (A0438), failing to ensure that medical record entries were timed by the person responsible for providing or evaluating the service provided (A0450), and failing to ensure that all medical records documented all nursing notes, reports of treatment, medication records and vital signs and other information necessary to monitor the patient's condition. (A0467)

Findings include:

1) Based on review of facility documents, review of medical records (MR) and staff interviews (EMP), it was determined that the facility failed to maintain a medical record for each outpatient, including ensuring that each record is promptly completed. (A0438)

2) Based on review of facility documents, review of medical records (MR) and staff interviews (EMP), it was determined that the facility failed to ensure that medical record entries were timed by the person responsible for providing or evaluating the service provided. (A0450)

3) Based on review of facility documents, review of medical records (MR) and staff interviews (EMP) it was determined that all nursing notes, reports of treatment, medication records and vital signs and other information necessary to monitor the patient's condition were not documented in medical records. (A0467)

Cross reference with:
482.24(b) Form and Retention Of Records
482.24(c)(1) Medical Record Services
482.24(C)(2)(vi) Content Of Record - Other Information

Based on review of facility documents, review of medical records (MR), and staff interviews (EMP), it was determined that the facility failed to maintain a medical record for each outpatient, including ensuring that each record is promptly completed for 15 of 15 medical records reviewed (MR7, MR8, MR9, MR10, MR11, MR12, MR13, MR14, MR15, MR17, MR18, MR19, MR20, MR24 and MR25).

Findings include:

Review of "Completion Requirements for Medical Records Date: December 2, 2009" revealed "I. Policy It is the policy of UPMC Presbyterian Shadyside (UPMCPS) including Western Psychiatric Institute and Clinic (WPIC) to provide guidelines for compliance with the completion requirements for medical records as indicated by ... the Pennsylvania Department of Health ... and other pertinent regulatory bodies. II. General The medical record must contain sufficient information to identify the patient, support the diagnosis, justify and document the course of treatment, evaluate pain, chronicle the results and promote continuity of care. ... B. The medical record should contain documentation of examination and treatments rendered to the patient. ... III. Completion Requirements ... F. Timely progress notes shall be written, dictated or typed to provide a pertinent chronological report of the patient's course of treatment. ... IV. Additional Record Completion Requirements For WPIC ... B. Ambulatory Records Portions of the ambulatory record may be documented in the electronic health record (EHR) and in paper form. Therefore, both the paper record and the EHR should be accessed for record review to insure that all information about the patient's treatment is considered. ... 6. Documention for each ambulatory service shall be completed in a timely manner."

1) Review of the DEC's (Diagnostic Emergency Center) computerized "White Board" patient tracking system/log revealed sections which indicated "Date to DEC ... Triage ... Triage Complete ... MD Decision ... Disposition" and a corresponding area to input the time for each.

Interview with EMP1, on February 18, 2010, at approximately 10:20 AM confirmed the above findings and revealed "MD Decision time is the time that the physician decided on what the patient's disposition would be, such as admission, discharge or transfer." During further interview, EMP1 confirmed that the "Date to DEC ... Triage ... Triage Complete ... MD Decision ... Disposition" times are not part of the medical record.

2) During an interview with EMP1 on February 18, 2010, at approximately 1:00 PM, EMP1 was asked how the DEC monitors patients while they are waiting for a medical screening exam and EMP1 stated "We do 15 minute [Therapeutic] observations on all patients in the DEC." Further interview with EMP1 revealed "They [Therapeutic Observation logs] are not part of the medical record ... We file them in a cabinet ... They are not sent to medical records."

3) During review of open medical records, review of MR1, MR2, and MR3 revealed a "DEC Nursing Flowsheet" form. Review of these flowsheets revealed that they included sections to document "Clinical Data" which included vital signs, alcohol and opiate withdrawal scores, glucometer and breathalyzer readings, and RN observations and interventions. Further review revealed sections to document medication administration, labs and tests, and fall risk assessments and interventions.

Review of MR7, MR8, MR9, MR10, MR11, MR12, MR13, MR14, MR15, MR17, MR18, MR19, MR20, MR24 and MR25 revealed no documented evidence of a "DEC Nursing Flowsheet."

During interview with EMP2 on February 23, 2010, at approximately 2:25 PM, EMP2 was asked for clarification about the "DEC Nursing Flowsheet" which was observed in MR1, MR2, and MR3 and not observed in MR7, MR8, MR9, MR10, MR11, MR12, MR13, MR14, MR15, MR17, MR18, MR19, MR20, MR24 and MR25. EMP2 stated "Every patient in the DEC has one [flowsheet] ... The only time the flowsheet goes into the medical record is if the patient becomes an inpatient."

During interview with EMP1 on February 23, 2010, at approximately 2:30 PM, EMP2 was asked if the DEC sends the flowsheets to medical records and EMP2 stated "No. We file the flowsheets into a cabinet down in the DEC."

4) Review of medical records during the investigation revealed that the DEC records requested appeared to have different information in them, different forms and/or documentation that other medical records would not. Overall review of these records revealed that the DEC medical records were unorganized and incomplete.

5) An interview was conducted with EMP3 on February 23, 2010, at approximately 2:25 PM. EMP3 was asked what constitutes a complete medical record from the DEC. EMP3 stated "We don't do any record analysis for ambulatory programs ... The DEC is an ambulatory program ... We only do it [record analysis] for inpatient records ... We just accept what they [DEC staff] send to us ... The record review of the DEC would be the responsibility of the DEC ... We are the custodian of the documents, we store everything. We aren't responsible for the DEC."

During further interview with EMP3, a review of the facility policy "Completion Requirements for Medical Records" was completed. During the review EMP3 was shown the sections of the policy "IV. Additional Record Completion Requirements For WPIC ... B. Ambulatory Records" and EMP3 stated "That does not include the DEC."

6) During interview with EMP2 on February 23, 2010, at approximately 2:40 PM, EMP2 was asked who was overall responsible for the completion of inpatient and outpatient medical records and EMP2 stated "[EMP3] is the Western Psych employee that is responsible for the health information."

Cross reference with:
482.24 Medical Records Service

Based on review of facility documents, review of medical records (MR), and staff interviews (EMP), it was determined that the facility failed to ensure that medical record entries were timed by the person responsible for providing or evaluating the service provided for 15 of 15 medical records reviewed (MR7, MR8, MR9, MR10, MR11, MR12, MR13, MR14, MR15, MR17, MR18, MR19, MR20, MR24 and MR25).

Findings include:

Review of "Completion Requirements for Medical Records Date: December 2, 2009" revealed "I. Policy It is the policy of UPMC Presbyterian Shadyside (UPMCPS) including Western Psychiatric Institute and Clinic (WPIC) to provide guidelines for compliance with the completion requirements for medical records as indicated by ... the Pennsylvania Department of Health ... and other pertinent regulatory bodies. II. General The medical record must contain sufficient information to identify the patient, support the diagnosis, justify and document the course of treatment, evaluate pain, chronicle the results and promote continuity of care. ... B. The medical record should contain documentation of examination and treatments rendered to the patient. ... III. Completion Requirements ... F. Timely progress notes shall be written, dictated or typed to provide a pertinent chronological report of the patient's course of treatment. ... IV. Additional Record Completion Requirements For WPIC ... B. Ambulatory Records Portions of the ambulatory record may be documented in the electronic health record (EHR) and in paper form. Therefore, both the paper record and the EHR should be accessed for record review to insure that all information about the patient's treatment is considered. ... 6. Documention for each ambulatory service shall be completed in a timely manner."

1) Review of MR7, MR8, MR9, MR10, MR11, MR12, MR13, MR14, MR15, MR17, MR18, MR19, MR20, MR24 and MR25 revealed a computerized "Multidisciplinary Psychiatric Evaluation Report."

Further review of the "Multidisciplinary Psychiatric Evaluation Reports" revealed that they contained four separate assessments "Triage Assessment ... Psychosocial Assessment ... Psychiatric Assessment ... Multiaxial Diagnosis."

Additional review revealed only one documented date and time on either the "Multidisciplinary Psychiatric Evaluation Report" or the four "Triage Assessment ... Psychosocial Assessment ... Psychiatric Assessment ... Multiaxial Diagnosis" reports.

2) Interview with EMP1 on February 18, 2010, at approximately 10:20 AM, confirmed the above findings and revealed "The report [Multidisciplinary Psychiatric Evaluation Report] is a combination of all four assessments [Triage Assessment ... Psychosocial Assessment ... Psychiatric Assessment ... Multiaxial Diagnosis] ... The report is a crystallized report ... all four of the reports form the Multidisciplinary report."

During further interview with EMP1, EMP1 was asked to confirm that the entries are not timed and EMP1 stated "No, they are not timed. It is a [computer] issue ... The only time that comes up on the report is the triage time ... The [computer program] does not have the ability to time entries."

Cross reference with:
482.24 Medical Records Service

Based on review of facility documents, review of medical records (MR), and staff interviews (EMP), it was determined that all nursing notes, reports of treatment, medication records and vital signs and other information necessary to monitor the patient's condition were not documented in medical records for 15 of 15 medical records reviewed (MR7, MR8, MR9, MR10, MR11, MR12, MR13, MR14, MR15, MR17, MR18, MR19, MR20, MR24 and MR25).

Findings include:

Review of "Completion Requirements for Medical Records Date: December 2, 2009" revealed "I. Policy It is the policy of UPMC Presbyterian Shadyside (UPMCPS) including Western Psychiatric Institute and Clinic (WPIC) to provide guidelines for compliance with the completion requirements for medical records as indicated by ... the Pennsylvania Department of Health ... and other pertinent regulatory bodies. II. General The medical record must contain sufficient information to identify the patient, support the diagnosis, justify and document the course of treatment, evaluate pain, chronicle the results and promote continuity of care. ... B. The medical record should contain documentation of examination and treatments rendered to the patient. ... III. Completion Requirements ... F. Timely progress notes shall be written, dictated or typed to provide a pertinent chronological report of the patient's course of treatment. ... IV. Additional Record Completion Requirements For WPIC ... B. Ambulatory Records Portions of the ambulatory record may be documented in the electronic health record (EHR) and in paper form. Therefore, both the paper record and the EHR should be accessed for record review to insure that all information about the patient's treatment is considered. ... 6. Documention for each ambulatory service shall be completed in a timely manner."

1) Review of the DEC's (Diagnostic Emergency Center) computerized "White Board" patient tracking system/log revealed sections which indicated "Date to DEC ... Triage ... Triage Complete ... MD Decision ... Disposition" and a corresponding area to input the time for each.

Interview with EMP1, on February 18, 2010, at approximately 10:20 AM confirmed the above findings and revealed "MD Decision time is the time that the physician decided on what the patient's disposition would be, such as admission, discharge or transfer." During further interview, EMP1 confirmed that the "Date to DEC ... Triage ... Triage Complete ... MD Decision ... Disposition" times are not part of the medical record.

2) During an interview with EMP1 on February 18, 2010, at approximately 1:00 PM, EMP1 was asked how the DEC monitors patients while they are waiting for a medical screening exam and EMP1 stated "We do 15 minute [Therapeutic] observations on all patients in the DEC." Further interview with EMP1 revealed "They [Therapeutic Observation logs] are not part of the medical record ... We file them in a cabinet ... They are not sent to medical records."

3) During review of open medical records, review of MR1, MR2, and MR3 revealed a "DEC Nursing Flowsheet" form. Review of these flowsheets revealed that they included sections to document "Clinical Data" which included vital signs, alcohol and opiate withdrawal scores, glucometer and breathalyzer readings, and RN observations and interventions. Further review revealed sections to document medication administration, labs and tests, and fall risk assessments and interventions.

Review of MR7, MR8, MR9, MR10, MR11, MR12, MR13, MR14, MR15, MR17, MR18, MR19, MR20, MR24 and MR25 revealed no documented evidence of a "DEC Nursing Flowsheet."

During interview with EMP2 on February 23, 2010, at approximately 2:25 PM, EMP2 was asked for clarification about the "DEC Nursing Flowsheet" which was observed in MR1, MR2, and MR3 and not observed in MR7, MR8, MR9, MR10, MR11, MR12, MR13, MR14, MR15, MR17, MR18, MR19, MR20, MR24 and MR25. EMP2 stated "Every patient in the DEC has one [flowsheet] ... The only time the flowsheet goes into the medical record is if the patient becomes an inpatient."

During interview with EMP1 on February 23, 2010, at approximately 2:30 PM, EMP2 was asked if the DEC sends the flowsheets to medical records and EMP2 stated "No. We file the flowsheets into a cabinet down in the DEC."

4) Review of medical records made during the investigation revealed that the DEC records requested appeared to have different information in them, with medical records having different forms and/or documentation that other medical records would not. Overall review of these records revealed that the DEC medical records were unorganized and incomplete.

5) An interview was conducted with EMP3 on February 23, 2010, at approximately 2:25 PM. EMP3 was asked what constitutes a complete medical record from the DEC. EMP3 stated "We don't do any record analysis for ambulatory programs ... The DEC is an ambulatory program ... We only do it [record analysis] for inpatient records ... We just accept what they [DEC staff] send to us ... The record review of the DEC would be the responsibility of the DEC ... We are the custodian of the documents, we store everything. We aren't responsible for the DEC."

During further interview with EMP3, a review of the facility policy "Completion Requirements for Medical Records" was completed. During the review EMP3 was shown the sections of the policy "IV. Additional Record Completion Requirements For WPIC ... B. Ambulatory Records" and EMP3 stated "That does not include the DEC."

Cross reference with:
482.24 Medical Records Service