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Based on medical record review and interview, the patient's medical record did not contain all pertinent information used by the provider in rendering patient care.

Findings:

On 12/26/09, a 29 year-old female patient with chronic renal failure on dialysis presented to the emergency department (ED) with an infected arterial venous (AV) graft. The graft had been surgically made 12 days prior. The patient had had a culture of the wound taken at dialysis that morning and given intravenous Vancomycin. Department physician review was critical that there was no documentation as to why no further lab studies were done and no medications were given in the ED. In addition, there was no documentation in the record to indicate the provider had spoken with the patient's vascular surgeon prior to discharging the patient to home.

Interview with the ED physician at 0900 on 7/15/10 revealed that the physician believed he would have spoken with a vascular surgeon prior to discharging the patient. He regretted not documenting the interaction in the record.