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WADLEY REGIONAL MEDICAL CENTER
CONTENT OF RECORD: ORDERS DATED & SIGNED
Tag No.: A0454
Based on record review, the facility failed to assure all orders were dated and timed. Six instance of undocumented date or time were observed in one of one patient chart.
Findings include:
Review of patient #1 ' s medical record revealed the following missing dates and times:
-Admission orders with no documented date
-Admission orders with no documented time
-No date on verbal order countersignature on 5/29/2011
-No time on verbal order countersignature on 5/29/2011
-No date on verbal order countersignature on 5/30/2011
-No time on verbal order countersignature on 5/30/2011
CONTENT OF RECORD: STANDING ORDERS
Tag No.: A0457
Based on record review, the facility failed to assure verbal orders were authenticated within 48 hours. Three instances of unauthenticated verbal orders were found in one of one patient chart.
Findings include:
Review of patient #1 ' s medical record revealed the following:
-Verbal order written on 6/02/11 was not authenticated
-Verbal order written on 6/10/11 was not authenticated x 2