HospitalInspections.org

Based on record review and interview the hospital failed to ensure that all medical records were promptly completed no later than 30 days after discharge as evidenced by having 1124 delinquent (incomplete and over 30 days since discharge) medical records awaiting medical record entries or completion of required signatures by the clinical staff in a total of 2041 discharge records (55% delinquency rate) dating as far back as 07/02/10. Findings:

In an interview on 01/04/12 at 10:20 a.m. with SF11RHIA, Health Information Management (HIM) Director and SF18RHIA both stated that there were 1124 delinquent medical records in the HIM department.

Review of a document provided by SF11RHIA, Health Information Management (HIM)Director, on 01/04/12 at 11:05 a.m., revealed there were 1124 delinquent medical records dating back to July 2010. The total number of discharges since July 2010 was documented to be 2041. The medical record delinquent rate for this period is listed as 55%. In an interview on 01/04/12 at 12:45 p.m. this delinquency rate was also confirmed by SF1Administrator and SF13Corporate Director of Patient Services.

Review of a hospital policy titled "Delinquent Records", policy number HIM031, no effective date, last revised 11/30/07, presented as current hospital policy, reads in part: "I. Policy: The patient's medical record will be considered complete when the required contents are assembled and authenticated...but not longer than 30 days from discharge...II. Purpose: To ensure the completeness of medical record information. III. Procedure: Health Information Management Personnel: A. A deficiency list is generated weekly for physicians and staff...D. The Health Information Management Department will prepare a delinquent record list weekly..."

Review of a hospital policy titled "Chart Analysis", policy number HIM029, no effective date, last revised 12/04/08, presented as current hospital policy, reads in part: "I. Policy: Qualitative and quantitative analysis will be performed on all discharged patients' medical records to check for both completeness and consistency. II. Purpose: To provide a thorough, accurate and complete medical record. III. Procedure: A. All medical records of discharged patients will be picked-up on-site by Health Information Management Department personnel the next day after discharge...C. The charts are reviewed for deficiencies and missing items are tagged for appropriate staff...D. The chart is checked for the following items:...5. Therapeutic Evaluations and Assessments...must be legible, signed, dated, and timed...7. Progress Notes (Physician, Nursing, Social Services, Therapy)...must be signed, dated, timed by the responsible clinicians...12. All entries on all forms must be dated, signed, and timed. No blanks are to be left on any form. All signatures must include credentials..."