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VHS HARLINGEN HOSPITAL COMPANY LLC
CONTENT OF RECORD: ORDERS,NOTES,REPORTS
Tag No.: A0467
Based upon reviews of medical record and reports, and interview with the facility's staff, the facility did not maintain a medical record for this patient admission that contained all reports.
Findings include:
a. Review of the medical record and reports at 10:00 a.m., November 16, 2011, in the facility's conference room revealed that the medical record did not contain the operative report for a surgical procedure performed on 21 November, 2008.
b. During interviews with the facility's Director of Health Information Management at 12:45 p.m., November 16, 2011, in the facility's conference room, following her own reviews of the medical record and reports, she verified that the facility's failed to complete the maintain a complete medical record for the patient, she could not find the operative report for procedure done on 21 November, 2008. She also verified that she could provide no evidence of the facility's compliance with this requirement.
CONTENT OF RECORD: FINAL DIAGNOSIS
Tag No.: A0469
Based upon reviews of medical record and reports, and interview with the facility's staff, the facility did not have a complete medical record for this patient admission within the required time.
Findings include:
a. Review of the medical record and reports at 10:00 a.m., November 16, 2011, in the facility's conference room revealed that the medical record was not complete within 30 calendar days following discharge. Investigator could not find the operative report for a surgical procedure performed on 21 November, 2008.
b. During interviews with the facility's Director of Risk Management at 12:10 p.m., November 16, 2011, in the facility's conference room, following her own reviews of the medical record and reports, she verified that the facility's failed to complete the medical record, she could not find the operative report for procedure done on 21 November, 2008. She also verified that she could provide no evidence of the facility's compliance with this requirement.
OPERATIVE REPORT
Tag No.: A0959
Based upon reviews of medical record and reports, and interview with the facility's staff, the facility did not have an operative report for procedure performed on patient.
Review of the medical record and reports at 10:00 a.m., November 16, 2011, in the facility's conference room revealed that the medical record did not contain an operative report for a surgical procedure performed on 21 November, 2008.
During interviews with the Surgeon that performed the surgical procedure at 11:40 a.m., November 16, 2011, in the facility's conference room, following his own review of the medical record and reports, he verified that the medical record did not contain an operative report for procedure performed on 21 November, 2008. He also verified that he could provide no evidence of the facility's compliance with this requirement.