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Based on observation, review of documentation, and an interview with staff # 4, the physician failed to authenticate medical orders; 2 of the applicable patients medical records did not contain the physicians ' signatures on 4 orders, according to facility policy all orders will be signed by the physician.
Findings
Review of medical record patient #8 and #10 revealed physicians orders 2/14/13 18:17, 2/15/13 20:04, 2/15/13 19:21, 2/15/13 20:16 were not signed by the physician.
Review of " Rules and Regulations of the Medical Staff of Reagan Memorial Hospital, 5. The attending physician is responsible for preparation of a complete medical record on each patient.
In an interview with staff #3 on the afternoon of 8/27/13 at the facility, the findings were confirmed.