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HIGHLAND COMMUNITY HOSPITAL
MEDICAL RECORD SERVICES
Tag No.: A0431
Based on observation of records in physician's incomplete file, review of Medical Staff Rules and Regulations, review of medical records of discharged patients, and staff interview, the hospital failed to ensure that the hospital's medical record service had administrative responsibility for medical records.
Findings include:
Cross Refer to A469 for the hospitals failure to ensure that all records of discharged patients were completed within 30 days of discharge.
FORM AND RETENTION OF RECORDS
Tag No.: A0438
Based on observation, review of Medical Staff Rules and Regulations, review of medical records, and interview with staff, the hospital failed to ensure that all medical records were promptly completed and properly filed.
Findings include:
Cross Refer to A469 for the hospital's failure to ensure that all x-ray reports filed on discharged patient's medical records were signed by the radiologist and for the hospital's failure to ensure that the medical records of discharged patients were completed within 30 days of discharge.
CONTENT OF RECORD: FINAL DIAGNOSIS
Tag No.: A0469
Based on observation, review of the resolution of the Board of Trustees approving amendments to the Medical Staff Rules and Regulations, review of medical records, and interview with staff, the hospital failed to ensure that all medical records were completed within 30 days of discharge.
Findings include:
A count of medical records in the physician's incomplete file was observed being made by medical record personnel on February 3, 2010. There were 716 records that were delinquent over 30 days following discharge. The majority of these medical records belonged to hospital patients, but also included outpatient records. These records lacked dictation and/or signatures, and dated back to 2007.
Review of the hospital's Medical Staff Rules and Regulations revealed they had been amended to suspend the admitting privileges of physicians who had not completed their medical records according to the delinquent medical record procedure. This amendment was approved by the Board of Trustees of the hospital on December 22, 2009.
Interview with the Administrator revealed that none of the physicians with delinquent records had been suspended as of February 5, 2010.