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LAWRENCE COUNTY HOSPITAL CAH
No Description Available
Tag No.: C0301
Based on review of Medical Staff Rules and Regulations, review of medical records, and interview with staff, the facility failed to ensure that all medical records are completed within 30 days of discharge.
Findings include:
1. Seventeen (17) discharged medical records were selected from a list of discharges from April 1, 2011, through August 15, 2011, and reviewed.
2. Beginning in April, 2011, medical records are scanned into the computer on discharge, and tagged for deficiencies for the physician to complete. On four (4) of the 17 medical records reviewed, the physician had not signed all of his entries. This included progress notes, orders and a history and physical exam.
On interview with the Director of Health Information Management (HIM), the surveyor questioned as to whether the records were considered still incomplete and waiting for the physician to sign them. The surveyor was told HIM only had two (2) incomplete medical records, and they were not any of the four (4) medical records that had been found incomplete. There is no system in place to monitor electronic record completion.
No Description Available
Tag No.: C0307
Based on review of Medical Staff Rules and Regulations, review of medical records, and interview with staff, the facility failed to ensure that all entries in the medical record were timed and were signed by the physician.
Findings include:
1. Seventeen (17) discharged medical records were selected from a list of discharges from April 1, 2011, through August 15, 2011, and reviewed along with three (3) inpatient medical records and the last four (4) discharges from the hospital for a total of 24 medical records.
2. On 24 of 24 medical records reviewed, the transcribed reports such as the history and physical exam and dictated progress notes did not include the time of dictation and time of transcription.
3. On seven (7) of 24 medical records reviewed, all physician orders had not been timed when entered into the medical record. This included those orders written by the physician as well as those verbal orders taken by a nurse.
4. On four (4) of 17 discharged medical records, all entries had not been signed by the physician. This included progress notes, orders and a history and physical exam. Refer to C0301.