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ST LUKE'S CORNWALL HOSPITAL
MEDICAL RECORD SERVICES
Tag No.: A0450
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Based on medical record (MR) review, document review and interview, the Emergency Department (ED) staff did not ensure signed Discharge Instructions were included in the MR, in 1 (one) of 3 (three) MRs reviewed.
Findings included:
Patient #1's MR identified the Patient Signature Page from the patient's Discharge Instructions was missing.
During interview of Staff A (Senior Vice President) on 5/9/19 at 12:10PM, Staff A confirmed the Patient Signature Page was missing from Patient #1's MR. Even after an extensive search of other MRs processed on the same discharge date as that of Patient #1, no signed Patient Signature Page was found for Patient #1.
A facility letter from Staff A to the surveillance team dated 5/9/19 stated, "...we agree that the signature sheet was not locatable in this situation..."