HospitalInspections.org

Based on a review of facility documentation and staff interviews, the facility failed to implement a requirement that a medical history and physical examination be completed and documented for each patient no more than 30 days before or 24 hours after admission or registration, but prior to surgery or a procedure requiring anesthesia services, as 7 of 10 patients did not have a valid history and physical in her clinical record.

Findings were:

A review of the clinical records of labor and delivery patients revealed that 7 of 10 patients [Patients #3-5, an #7-10] had either no or an incomplete history and physical, or one that was older than 30 days.

A review of the clinical record of Patient #2 revealed no history and physical.

The record of Patient #10 showed a date of service of 1/20/15. A history and physical in the chart completed in the physician's office and FAXed to the facility by the office included no date on the form other than a FAX date of 1/21/15.

Patient #4 received hospital services on 4/6/15. The history and physical in her chart was dated 3/13/15. There was no documented update to her status made by a physician available for review in her record.

The clinical records of Patients #5, and #7-9 revealed an incomplete history and physical with no review of systems. While a history and physical completed in the office of a physician was available for each patient, the examinations were older than 30 days and included no update to patient status. As an example, a history and physical for Patient #8 (date of service: 4/6/15) was completed on 1/26/15 in the physician's office.

The Seton Family of Hospitals Medical Staff Rules stated, in part:
"(G) History and Physical (H&P) Examination Requirements
(1) Admission History and Physical
A medical history and physical (H&P) examination must be completed no more than 30 days before or within 24 hours of admission for each patient by a physician or other individual qualified to perform the medical history and physical examination ...

The medical history and physical examination must be placed in the patient's medical record within 24 hours after admission.

If the admission H&P is less than 30 days old, but was not performed at the time of admission, the patient's medical condition at the time of admission shall be documented by the physician or other individual qualified to perform the medical history and physical examination ...

(11) Performance of H&P ...
At a minimum the H&P must be completed prior to the procedure and must include the following:
(a) Diagnosis;
(b) Relevant history;
(c) Relevant medication history;
(d) Documentation of a current physical examination;
(e) Diagnostic studies; and
(f) Plan for treatment ... "

Facility policy entitled Indications for a Qualified Pre-procedural History and Physical Exam, last reviewed 1/09, stated in part:

"The SETON Medical Staff Rule II-F-1 requires all inpatients have a qualified history and physical recorded in the chart or dictated within twenty-four (24) hours of admission as an inpatient ...The SETON Medical Staff Rule II-F-2 requires that a patient's History and Physical be in the medical record prior to any "Required Procedure" except for those patients requiring emergency interventions ... "

In an interview with Staff #3, Quality Specialist, and Staff #1, Clinical Nurse Manager, on the morning of 4/16/15 in the facility meeting room, they agreed the patient charts specified above did not include documented evidence of a history and physical examination that met facility or regulatory requirements.