HospitalInspections.org

Based on the review of medical records, it was determined that in five of five maternal medical records, medical records # 1, 3, 5, 7, and 9, and four of five newborn medical records, medical records # 2, 6, 8, and 10, the hospital failed to ensure that all patient medical record entries were dated, timed, and authenticated. Findings:

The review of medical records revealed that each individual's medical record consisted of a hard copy and an electronic portion. The failure to date, time, and authenticate entries was identified in the hard copy of both maternal and newborn medical records and included the following:

The following entries or forms in the maternal medical records lacked documentation of the time and/or date:
The Obstetric Discharge Summary Form in medical records # 1, 3, 5, 7, and 9;
The initial Nursing Learning Assessment form in medical records # 1, 3, 5, 7, and 9;
The Mother Discharge Instructions form in medical records # 1 and 9;
The PreAnesthesia Note in medical records # 1 and 7; and
The Post Anesthesia note in medical records # 1, 5, and 9. Medical record # 7 lacked documentation of a Post Anesthesia note.
The Patient Site Verification Checklist form in medical record # 1 lacked documentation of the date and time.
The Patient Consent for Circumcision in medical record # 1 lacked documentation of the time.

The following entries or forms in the newborn medical records lacked documentation of the time and/or date:
The preprinted Newborn Admission physician orders form in medical records # 6 and 8;
The Newborn Evaluation/Progress Record in medical records # 6, 8, and 10;
The Interdisciplinary Patient Plan of Care - Newborn in medical record # 8;
The Newborn Post Delivery Medications form in medical records # 2 and 6; and
The Newborn Discharge Instructions form in medical records # 2 and 10.

The preprinted Perinatal Labor Admission form in medical record # 7 contained the following order checked by the Certified Nurse Midwife: "Fentanyl 50-100 microgram intravenously every ____hour as needed for pain". The order lacked documentation of the frequency of the medication administration.


-These findings also reflect noncompliance with the following Oregon Administrative Rule for Hospitals:
333-505-0050(7) Medical Records requires that all entries in a patient's medical record shall be dated, timed and authenticated.