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SENTARA NORFOLK GENERAL HOSPITAL
HISTORY AND PHYSICAL
Tag No.: A0952
Based on document review and interview, it was determined that the facility failed to have an updated history and physical prior to surgery or a procedure requiring anesthesia services for two (2) of eleven (11) patients (Patients # 10 and # 11).
The findings include:
On August 22, 2018 at 11:10 a.m. a document review for Patient # 10, with Staff Member # 3 navigating the electronic record, revealed the patient was admitted on August 8, 2018 as a direct admission for an elective procedure requiring anesthesia. Patient # 10 had an transcatheter aortic valve replacement (TAVR) via femoral artery approach on August 8, 2018 at 10:50 a.m. The history and physical (H&P) was completed by Staff Member # 17, Nurse Practitioner, on August 8, 2018 at 10:26 a.m. The H&P was cosigned by Staff Member # 15, Cardiologist, on August 8, 2018 at 5:58 p.m. after the procedure was completed. Staff Member # 3 and Staff Member # 10 confirmed there was no update to the H&P prior to the procedure.
On August 22, 2018 at 11:25 a.m. a document review for Patient # 11, with Staff Member # 3 navigating the electronic record, revealed the patient was admitted on August 8, 2018 as a direct admission for an elective procedure requiring anesthesia. Patient # 11 had mitral valvuplasty on August 8, 2018 at 1:46 p.m. The H&P was completed by Staff Member # 17, Nurse Practitioner, on August 7, 2018 12:14 p.m. The H&P was cosigned by Staff Member # 16, Cardiologist, on August 8, 2018 at 6:07 p.m. after the procedure was completed. Staff Member # 3 and Staff Member # 10 confirmed there was no update to the H&P prior to the procedure.
The document review findings were discussed with Staff Members # 2, # 3, # 10 and # 13 during the exit interview on August 22, 2018 at 2:00 p.m.