HospitalInspections.org

Based upon review of medical records and interview with staff it was observed that there were medical records that had verbal orders that were not dated, timed and or authenticated by physicians within 48hours as per federal and state law. This requirement was not met as follows:


Findings:

a. In a review of 33 patient medical records, 4 out of 33 (12%) medical records
reviewed had verbal/telephone orders that were not dated, timed and/or authenticated by the prescribing physician within 48 hours.

b. Interviewed staff #1, Regional Director of Quality and key staff at 1:00pm on
February 9, 2012 in a conference room at Baptist Medical Center to inform staff of the deficiency. Staff agreed that this is an ongoing performance improvement project in decreasing the percentage of verbal/telephone orders that are not dated, time and authenticated by the prescribing practitioner within 48 hours.