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Based upon review of medical records and interview with staff it was determined that 18 out of 23 (78%) (MR# 1,2,3,4,5,6,7,8,9,11,12,17,18,19,20,21,22, and MR#23) of medical records reviewed that were incomplete which included medical record entries that were either not dated, timed or authenticated in written or electrical form by the person responsible for providing or evaluating the services provided, consistent with hospital policies and procedures. This requirement is not met as follows.

Findings:

a. Reviewed 23 medical records (MR # 1-23) there were 18 out of 23 (78%) of the medical records reviewed (MR# 1,2,3,4,5,6,7,8,9,11,12,17,18,19,20,21,22, and MR#23) that had medical entries or authentications that were either not dated and/or timed and/or authenticated. These medical entries ranged from progress notes, history and physicals, operative notes, medication reconciliation forms, discharge summaries, care plans and regular physician orders that were not dated or timed. There were 7 out of the 23 (30%) medical records (MR# 1,2,5,6,9,17 and MR# 19) reviewed that had verbal orders that were not timed and/or dated by the provider within 48 hours.

b. Interviewed staff #2, Director of Health Information Management (HIM) at 2:30pm on March 9, 2010 in the administration conference room and explained and showed examples of medical entries that contained missing dates, times or authentications that were missing date and/or time. Staff member interviewed could not provided evidence that the medical record reviewed met the requirements of this regulation.

Based upon review of medical records and interview with staff it was determined that 18 out of 23 (78%) (MR# 1,2,3,4,5,6,7,8,9,11,12,17,18,19,20,21,22, and MR#23) of medical records reviewed that had medical entries that did not have dated signatures of the doctor or osteopathy or other health care professional. This requirement is not met as follows.

Findings:

a. Reviewed 23 medical records (MR # 1-23) there were 18 out of 23 (78%) of the medical records reviewed (MR# 1,2,3,4,5,6,7,8,9,11,12,17,18,19,20,21,22, and MR#23) that had medical entries or authentications that were either not dated and/or timed and/or authenticated. These medical entries ranged from progress notes, history and physicals, operative notes, medication reconciliation forms, discharge summaries, care plans and regular physician orders that were not dated or timed. There were 7 out of the 23 (30%) medical records (MR# 1,2,5,6,9,17 and MR# 19) reviewed that had verbal orders that were not timed and/or dated by the provider within 48 hours.

b. Interviewed staff #2, Director of Health Information Management (HIM) at 2:30pm on March 9, 2010 in the administration conference room and explained and showed examples of medical entries that contained missing dates, times or authentications that were missing date and/or time. Staff member interviewed could not provided evidence that the medical record reviewed met the requirements of this regulation.