HospitalInspections.org

Based on staff interview and medical record review the CAH failed to ensure timed and dated signatures on physician's orders for 5 of 11 medical records (P4, P6, P9, P10, P11) reviewed. Findings included:

Review of the medical record for P4, admitted on 8/23/2010 for a laparoscopic cholecystectomy, indicated the Surgical Requisition lacked the time of the physician's signature.

Review of the medical record for P6, admitted on 8/24/2010 for an orthoscopic knee procedure, indicated the Surgical Orders lacked the date and time of the physician's signature.

Review of the medical record for P9, admitted on 8/24/2010 for an orthopaedic hand procedure, indicated the Surgical Requisition lacked the time and date of the physician's signature.

Review of the medical record for P10, admitted on 8/23/2010 for a esophagogastroduodenoscopy, indicated the Surgical Requisition lacked the time of the physician's signature.

Review of the medical record for P11, admitted on 8/23/2010 for a colonoscopy, indicated the Surgical Requisition lacked the physician's signature as well as the date and time of the order.

The lack of time/date/signatures on medical records was confirmed by the clinical informatics at 12:30 pm on 8/26/2010.





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