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MEDICAL CITY ARLINGTON
MEDICAL RECORD SERVICES
Tag No.: A0450
Based on record review and interview, the hospital did not accurately document 1 of 1 patient's (Patient #1) Operative Report. The report reflected Physician #7 assisted Physician #6 in Patient #1's surgical procedure on 2/5/13. Personnel #8 was the one who assisted Physician #6.
Findings included:
Patient #1 underwent a surgical procedure, "open reduction internal fixation of the right hip..." on 2/5/13. The Operative Report electronically signed on 2/7/13 indicated "Assistant: Physician #7" assisted Physician #6 with Patient #1's surgical procedure. This was not accurate. Personnel #8 was the individual who assisted Physician #6.
In an interview on 12/15/14 between 9:50 AM and 10:00 AM, Personnel #3 and Personnel #5 were asked if Physician #7 assisted Physician #6. Personnel #3 replied Physician #7 had been inactive since 2010. Personnel #3 stated the Operative Report was inaccurate. Personnel #8 was the individual who assisted Physician #6.