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Based on interview and record review, the hospital failed to ensure History and Physical (H & P) was completed prior to procedures for two of five records reviewed (Patient 16 and 17). This had the potential to affect these patients' overall outcome associated with the procedure.

Findings:

On December 28, 2010 at 3 PM, with assistance from the Clinical Information System Coordinator (CISC), five patients' records were reviewed. These five patients had surgical procedures or endoscopic procedures completed in the past two weeks at the hospital. The following issues were identified:

1. Patient 16 had a procedure done in the Endoscopic Department at the hospital on December 20, 2010. The H & P for Patient 16 was blank.

2. Patient 17 had a procedure done in the Endoscopic Department at the hospital on December 15, 2010. The patient 's H & P had only allergies and vital signs (temperature, pulse, respiration, blood pressure and oxygen saturation) documented.

On December 28, 2010 at 5 PM, during an interview, the Director of Accreditation and Special Projects stated the pre-procedure H & P used in its Endoscopic Department was a short form and should have been completed prior to the procedure taking place.

On December 28, 2010 at 5:10 PM, the hospital's Policy on "Medical Records Content Policy" was reviewed. Under "OUTPATIENT SURGERY/INVASIVE PROCEDURES-SPECIAL CONSIDERATIONS" read in part, "An abbreviated history and physical can be utilized for all patients treated as outpatients and shall consisted of all the elements of the comprehensive history and physical, with a provision that the information may ... At a minimum, the written physical exam (dictated and transcribed or hand written) shall include:

? Medical history
? A review of the system
? Allergies
? Major complaints
? Reason for operative procedure
? Initial diagnosis."